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THE NEW PUBUC HEALTH 

H. W. HILL 



The New Public Health 



BY 



HIBBERT WINSLOW HILL, 

M. B., M. D., D. P. H. ^ ' 

Director: Institute of Public Health, 
London, Ontario 

Late Director: Division of Epidemiology, 
Minnesota State Board of Health 






First published as a series of eleven monthly articles 

by the Journal-Lancet of Minneapolis, 

under the auspices of the 

Minnesota State Board of Health 



MINNEAPOLIS, MINN. 
PRESS OF THE JOURNAL-LANCET 

1913 



.H5 



D. OF D. 
MAY 81 1913 



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PREFACE 

The Problem. — Until such time as poverty is abol- 
ished, or the State takes charge of children, the major- 
ity of the women of the race must continue to rear the 
majority of the children of the race inadequately, in 
homes too small, without facilities, doing for them 
somehow, individually and alone, that which three 
women could hardly do well, working together. 

This is not wholly a slum problem nor is it a prob- 
lem of the rich. Numerically the race is chiefly middle 
class, neither rich nor extremely poor, judged by or- 
dinary standards. This is the problem of the family 
with an income below $3,000, i. e., it is the problem 
of the race proper, and it is the old problem of the 
pre-mosaic Hebrew^how to make bricks without 
straw — alas, often wit-hout knowing how to make 
bricks at all. 

The problem as a whole involves food, clothing, 
proper physical development, morals, education, 
amusement, discipline, and citizenship. But the public 
hygienist has as yet but indirect concern with these. 
The public hygienist — the ''board of health man" — as 
yet concerns himself chiefly and by general expecta- 
tion and consent, with the grosser, more imminent, 
more spectacular, more iilnnediately tragic problems 
of disease and death, and chiefly with only one group 
of these, the infectious diseases. However much in 
ordinary life over-crowding, lack of facilities and over- 
burdening of mothers may render unavailing even the 
tears and ageing, the back-ache, heart-ache, crooked 
fingers and wrinkled faces of mothers striving for 
their young, ten times over is the effect of these seen 
when disease enters the family, adding its burdens, 
its sorrows, its disabilities and its deaths. 

Once more, remember this is not in the slums 
alone, nor, numerically, chiefly there. It is found in 
city and country, village and town, everywhere, the 
overburdening of mothers, in ordinary life, added to 
ten times over when disease springs up. 

How Big A Problem Is It? — Call the population 
of the United States 80,000,000. Remember that sooner 



or later, every member of each generation suffers 
from at least one infectious disease, often from two, 
three or four, and it is clear that every generation 
suffers anywhere from 80,000,000 to 240,000,000 at- 
tacks of infections. Each generation pays out "at least 
eight billions of dollars for this running of the gaunt- 
let, not to speak of the disability and death of those 
who run it successfully. Tuberculosis, diphtheria, 
summer diarrhea, scarlet fever, measles, typhoid fever, 
whooping cough, chickenpox, to name only some of 
those best known to the laity, how much sorrow, dis- 
tress, poverty, how much ''making of none avail" of 
mothers' hopes and prayers and wearing effort have 
these caused! Yet so - common are they that ''chil- 
drens' diseases" are looked upon as a necessary stage, 
almost a joke. Indeed some people deliberately ex- 
pose their children to them, ''to have it over with!" 
Yet who bears the burden, the sleepless nights, the 
extra work, the hope deferred? 

Ninety-five per cent of the infectious diseases are 
nursed at home by mothers. Next to the children 
themselves the ones who suffer most are mothers. 

Who Keeps the Infectious Disease Going? — Once 
more the answer is — and m.ost emphatically — 
women in general but chiefly after all the mother. 
To be sure there is every excuse for the mother, 
— overwork, overcrowding, lack of facilities, above 
all ignorance and misdirected training, "misin- 
formation piled on lack of any." But with all the 
perfectly good apologies stated and all the excellent 
good-will and effort counted in, the fact itself remains, 
that mothers propagate and keep alive and spread the 
infectious diseases of children more than any other 
one body of people, and that while conditions remain 
as they are they must learn the "rules of the game" 
and follow them, for no amount of coaching or effort 
from the sidelines can do more than help. 

Why and How Are Women Responsible? — Because 
mothers are doing the work — women in general, but 
chiefly mothers. The farmer is responsible (apart 
from flood, drought, storm or other "acts of God") 
for whatever happens to the crop from seed to market. 
Women in general — but chiefly mothers — are the 
"raisers" and "crop-handlers" of the larg-est, most 
valuable, most expensive and most difficult crop in 
the country. What happens to this crop between 
birth and sixteen years of age is, chiefly, what women 
do to it, or at least do not prevent. For the first 
5,000 days of the years of the life of each generation. 



the race is fed, dressed, undressed, washed, coml)ed, 
cuddled, kissed, praised, blamed, led, driven, coaxed, 
taught, spanked, bossed and otherwise "brought up" 
by women — women mothers at home, women teachers 
at school. It is chiefly during this time of tutelage 
and supervision l)y women that children receive their 
infections; it is during this time that the race runs its 
gauntlet, dances its little dance with death — and pays 
eight billions for it. 

Present Attempts. — To tea.ch women, girls, pro- 
spective mothers, that they may practice in their house- 
hold and in turn teach their children to war on in- 
visible germ-foes is one of the functions of public 
health bacteriology. Only in the public schools can 
it be taught with emphasis, weight and uniformity 
enough to impress the masses. Only if taught in the 
grades can it be counted upon to reach the masses. 
Less than i per cent of the population reach the 
university, only lo per cent reach the high schools. 
The great mass of the mothers of the coming genera- 
tion, of the whole race, the mothers of more than 
their average of children, are receiving grade school 
education only. Need more be said? 

The infectious diseases in general radiate from and 
are kept going by women. Women must learn to 
break up, divert, stop in some manner — in every man- 
ner — the exchange of infected discharges amongst 
children at school and amidst families at home if in- 
fectious diseases are to be abolished or abated under 
present conditions. The needful information, beliefs, 
technique and habits cannot .be had or established ex- 
cept by studying the basic principles of public health, 
and this must be taught in the grades of the public 
schools if it is to reach those who most need it. 

Radical Changes in Social Conditions the Real So- 
lution. — If (as cannot be) every girl now at grade 
school could be thoroughly taught all that a trained 
nurse knows, theory and practice, the best to be hoped 
is that, becoming a mother, ten to twenty years hence, 
she may remember enough to care for, if she have 
the facilities, the first case of infection in her house- 
hold without permitting its spread to the other mem- 
bers or to outsiders. Alas, not one third of the girls 
will remember, not one-tenth will have the facilities. 
Above all what shall be done in that intervening ten 
to twenty years? Lectures, writings, sermons, appeals 
to mothers' clubs, university extensions, moving pict- 
ures, all the publicity that can be had or hoped for, 
will not suffice to ^each technique to the mother now 



in possession of the coming generation. Nor once 
more, if it taught them, would it provide the facilities 
needed. Economic conditions must change and change 
specifically to aid the mother if we are to gain at all. 
Also, the prevention of disease must engage the 
serious attention of governments — the prevention of 
disease, not the talking about it or the looking wise 
over it, or the making of fine addresses on it, but 
preventing it. Such prevention may include a tremen- 
dous organization to prevent human discharges enter- 
ing water supplies, milk supplies, food supplies; must 
involve watchfulness of hotels, restaurants, public in- 
stitutions of all sorts — in short, of all public alimen- 
tary utilities, with all their off-shots and side issues 
wherever found. The whole must be cooperative. 
The government must strike at the sources and at the 
public routes of infection. The woman must strike 
at the private routes. The man must support both 
methods for the sake of the women and children. 



TABLE OF CONTENTS 

Page. 

Chapter I. THE OLD PRINCIPLES AND THE NEW 9 

The Revolution 9 

The Old Teachings 11 

The New Ideas, 13 

Environment 14 

Chapter II. INFECTIOUS DISEASES 16 

Facts 16 

(a) Sources of Infectiotis Diseases. . . 19 

(&) Routes of Infectious Diseases. . 21 

(c) Control of Infectious Diseases. . 22 

Chapter III. NON-INFECTIOUS DISEASES 23 

Speculations 23 

The General Problem 25 

The Present Situation 27 

Immediate Possibilities 30 

Education 32 

Medical Supervision of Schools 34 

Summary 36 

Chapter IV. THE OLD PRACTICE AND THE NEW 39 

Epidemiology 39 

Comparative Methods 40 

The New Emergency Epidemiology... 43 

Finding the Unknown Cases 47 

Summary 48 

Chapter V. THE NEWEST PRACTICE 50 

Concurrent Epidemiology 50 

Future Applications 54 

Chief Infectious Diseases, Classified 

by Routes 57 

The New Program 59 

Chapter VI. INDIVIDUAL DEFENSE 63 

Public Defense and Private 63 

The Preventability of "Preventable'" 

Diseases 63 

"Dodging Infection"" 66 

^'Contact" 67 

Placard for Schools 72 

Summary 76 



Chapter VII. COMMUNITY DEFENSE 78 

The Public Health Engineer 78 

Summary 85 

Chapter VIII. COMMUNITY DEFENSE S7 

The Public Health Laboratory 87 

Summary 93 

Chapter IX. COMMUNITY DEFENSE 94 

The Public Health Statistician 94 

Statistics as They Will Be 95 

Statistics as They Are 98 

Summary 106 

Chapter X. COMMUNITY DEFENSE APPLIED.... 108 

Tuberculosis in General . 108 

Human Tuberculosis 109 

The Abolition of Cattle Tubercu- 
losis of the Human 112 

The Abolition of Human Tubercu- 
losis 113 

Summary 119 

Chapter XL THE CONCLUSION OF THE WHOLE 

MATTER 121 

The Doing of It 121 

The Chief Objections 121 

Popular Fallacies 125 

New Fashioned Quarantine 126 

Summary 128 



THE NEW PUBLIC HEALTH 

Chapter I 
THE OLD PRINCIPLES AND THE NEW 

THE REVOLUTION 

The statement that there is a ''New PubHc 
Health" may shock those who, although famiHar 
with recent changes in scientific thought, yet 
have not fully realized what those changes mean ; 
but the shock will be far greater to those who 
have not appreciated that changes were going on. 

The purpose of the writer is to formulate for 
both groups, the unconscious progressive and the 
unconscious conservative, a brief statement of 
the essential principles of modern official public- 
health work. To those who may feel skeptical as 
to the fairness of this exposition, the writings of 
Chapin, the great American pioneer of modern 
public health, of E. O. Jordan, and of M. N. 
Baker, may be ofifered as bearing directly upon 
these questions, while the whole of modern tech- 
nical public-health literature may be ofifered as 
indirect evidence. 

The old principles have merged gradually into 
the new, in keeping with the experiments, ob- 
servations, and conclusions of many investigators 
in many individual sciences related to general 
public health. Within official public-health cir- 
cles, bacteriology, clinical observation and mathe- 
matics have furnished most of the reconstruction. 
The bacteriologist, the epidemiologist, and the 
vital statistician, sometimes working together, 



more often alone, in the dark and even at cross 
purposes, have nevertheless all reached the same 
point, and today each finds his co-workers be- 
side him. Much of the work done has consisted 
in clearing away the fallacies built up by tradi- 
tion, but construction-work has gone on also, and 
it is now possible to formulate the results. 

The essential change is this : The old public 
health was concerned with the environment, the 
new is concerned with the individual. The old 
sought the sources of infectious disease in the 
surroundings of man ; the new finds them in man 
himself. 

The old public health sought these sources in 
the air, in the water, in the earth, in the climate 
and topography of localities, in the temperature 
of soils at four and six feet deep, in the rise and 
fall of ground-waters ; it failed because it sought 
them, very painstakingly and exhaustively, it is 
true, in every place and in every thing where 
they zvere not. 

The new pubHc health seeks these sources — 
and finds them — amongst those infective persons 
(or animals) whose excreta enter the bodies of 
other persons. 

The old public health failed to find the sources 
of infection ; it also failed in most instances to 
find the routes of transmission. It is true that 
public water-supplies were detected as at times 
transmitting infection ; but milk was hardly sus- 
pected twenty years ago, and flies, suggested in 
1887"^', were not seriously considered until the 
Spanish-American war; mouth-spray "^ * and 

*Wm. H. Welch: Address at the Annual Meeting of 
the Medical and Chirurgical Faculty of Maryland 1887, 
quoted in "Sewage and Local Drainage. " — Wearing-. 1889. 

**By this is meant the fine droplets thrown out from 
the mouth in speaking, singing, laughing, sneezing, 
coughing, etc. 

10 



hands have been only recently recognized as im- 
portant. On the other hand, dirty clothes, bad 
smells, damp cellars, leaky plumbing-, dust, foul 
air, rank vegetation, swamps, stagnant pools, cer- 
tain soils, smoke, garbage, manure, 'dead animals, 
in fact everything physically, sensorially, esthet- 
ically or psychically objectionable, were lumped 
together as ''unsanitary" without much distinc- 
tion of ''source" or "route," and were regarded 
as a sort of general "cause of disease" to be con- 
demned, wherever found, "for fear of epidem- 
ics." 

THE OLD TEACHINGS 

It was taught that infectious diseases "gener- 
ated" in the foul, ill-smelling, unventilated, sun- 
less hovels of the slums. In the vogue of those 
days, "the slum-dwellers live like pigs, and there- 
by invoke the coming of smallpox, scarlet fever, 
typhoid fever, diphtheria." When these diseases 
invaded the home of the well-to-do, where this 
explanation was not seemly, a pinhole leak in 
some plumbing fixture accounted amply for diph- 
theria ; rotten potatoes, forgotten in a dark corner 
of the cellar, for typhoid fever ; scarlet fever was 
traced to a letter from a friend who had had the 
disease months before; smallpox to unpacking 
books used by a patient a quarter of a century 
previously ; manure piles gave rise to cholera ; 
and dampness to malaria, which was not recog- 
nized as transmissible at all. Yellow fever orig- 
inated in impure water and was directly transmit- 
ted from person to person — a typical example of 
intense direct contagion ; tuberculosis was non- 
infectious and hereditary ; bubonic plague was 
banished from the Egyptian Cairo "simply by 
improving the ventilation of the city" ( !)* 

*Parke's Hyg-iene, 1891; eighth edition. This was a 
standard work of twenty years ago. 

11 



Remedial and preventive measures, based on 
such beliefs in the omnipotence of environment, 
naturally sought to remodel the lives and im- 
mediate home surroundings of the whole popula- 
tion to conform with a vast array of alleged 
''sanitary laws of health." Yet he who seeks for 
a scientific demonstration of the relations existing 
between disobedience of these ''sanitary laws" 
on the one hand, and the incidence of disease and 
death on the other, will find only a "twilight 
zone" in which move vague shadows of tradition- 
al fear, shadows which, on probing, fade mistily 
away. 

The New Public Health is not worried by 
elaborate theoretical po3sibilities, but concerns 
itself earnestly with practical probabilities. The 
occasional, unusual, bizarre routes of infection 
in the one per cent of cases, do not distract its 
attention from the usual, practically constant, 
simple, ordinary routes concerned in the ninety- 
nine per cent. Its main postulate is that the 
routes of infection are simply the routes of in- 
fected bodily discharges, which, again, are iden- 
tical with the routes of ordinary uninfected dis- 
charges in ordinary life. 

The old style "sanitary inspector" was expect- 
ed to, and usually did, "condemn" everything in 
sight, from the garbage-pail at the back door to 
the plumbing in the bath-room. But disease 
continued, because he was condemning, as a rule, 
so far as health was concerned, things largely 
"incompetent, irrelevant, and immaterial." What 
availed it that the garbage-pail was emptied every 
day or a vent-pipe placed on the bath-water 
waste-trap, if the milkman delivered scarlet-fever- 
infected milk at the door, or an unrecognized 
case of measles sat next the children at school? 

12 



THE NEW IDEAS 

The New Public Health sees in the garbage- 
pail merely a place where flies are fed and, pos- 
sibly, bred. But the flies cannot carry infection 
// infected discharges are not accessible to them. 
''Defective plumbing," such a nightmare twenty 
years ago, has been conclusively shown to have 
nothing to do with disease-generation or disease- 
propagation whatever, unless perchance there be 
actual gross leakage of infected sewage. The 
unventilated front parlor could not produce tuber- 
culosis in a hundred years ; diphtheria does not 
develop from the family well ; and typhoid fever 
in sand or clay soils is but seldom properly trace- 
able to that source, either. The modern pubHc 
health man cares nothing, so far as restriction of 
disease and death is concerned, for the dirty back 
yard or the damp cellar in thernselves, but only as 
they may enter into the transmission of infected 
discharges. Then, at once, they become of vital 
importance. The sanitary inspection of the mod- 
ern sanitarian, so far as relates to infection, be- 
gins and usually ends with the search for (a) the. 
infected individual; (b) the routes of spread of 
infection from that individual; (c) the routes of 
spread of the ordinary excreta of ordinary unin- 
fected individuals to the mouths of their ordinary 
associates in ordinary life. These latter are 
sought for, not because of danger from such 
uninfected discharges, but rather because in- 
fected discharges, introduced into and following 
the same well-beaten paths, will necessarily reach 
the same mouths. To locate all the infective per- 
sons and to guard all their discharges would be 
wholly sufficient, but since this cannot always be 
done perfectly, it is well to guard also the routes 
which unlocated infection may take. 

13 



ENVIRONMENT 

Has environment, then, nothing to do with in- 
fectious diseases? Environment acts in two 
ways : First, unequivocally and without reserve, 
such environments as permit or encourage or, 
still worse, necessitate the exchange of human 
excreta in ordinary life, contribute in the long 
run to the spread of disease since they insure a 
similar exchange of infected excreta so soon as 
the latter are introduced."^ Let us take one en- 
vironmental evil, overcrowding, as an example. 
Overcrowding, if combined with lack of discipline 
and order, and lack of facilities for washing, 
especially for the washing of hands, contributes 
to the spread of infectious diseases ; but not in 
itself, nor at all, unless infection be introduced 
into the community. Then overcrowding, because 
it tends to insure exchange of human excreta, 
tends also to insure that the infection will spread 
rapidly and extensively. But overcrowding, if 
the overcrowded be disciplined, intelligent, and 
take proper precautions to avoid exchange of 
excreta, does not necessitate the spread of in- 
fection, even if it be introduced. On the other 
hand, infection may spread, and frequently does, 
without overcrowding, if the essential factor of 
such spread exist, i. e., the transmission of in- 
fected excreta. 

Second. Environments that are bad from a 
physiological standpoint (bad for the body, re- 
garded as a delicate biological machine) are 
often held to act in spreading infection indirectly 
by ''depressing vitality" to an extent which makes 
infection, if received, more likely to develop (and 
if it develop, more successful in injuring the 

*An exceUent exposition of this effect of environment 
on the spread of disease is g-iven by Chapin in the Re- 
port of the Providence Health Department for 1910. 

14 



body.) It must be said, however, that the evidence 
on this point, except perhaps that relating to 
tuberculosis and pneumonia, is very slight. It is 
a debatable question whether or not overcrowd- 
ing ''depresses vitality" in the direction of in- 
creasing susceptibility to infectious diseases, 
whatever its effects may be in encouraging ''gen- 
eral debility." It is a very debatable question 
whether or not "poor ventilation" to which the 
effects of overcrowding are often attributed, can 
or does "depress vitality" in the direction of 
lessening resistance to infectious diseases, what- 
ever bad effects it may have on mental vigor or 
physical activity. It is true that there is evidence 
that such environments as lead to extremes 
(beyond the limits of compensatory adjustments 
by the body forces) of mal-nutrition, of temper- 
ature, of fatigue, and of alcoholism, probably 
may have an effect in insuring the development 
of infection, which under better conditions might 
be negatived by the body forces. Especially may 
these forms of bad physiological environment be 
influential when the dose of infection is small, 
infrequent, or low in virulence. But starvation, 
unsuitable temperature, fatigue, alcoholism, 
alone or together, cannot induce infection, nor 
will the converse conditions, alone or together, 
offset the effects of infection when the dose is 
large or frequently repeated or of high virulence. 



15 



Chapter II 
INFECTIOUS DISEASES 

FACTS 

It would appear, then, that environments af- 
fecting bodily functions have little to do directly 
with the incidence of most of the specific infec- 
tions,* notwithstanding that nutrition, tempera- 
ture, fatigue, and alcoholism are generally cred- 
ited with some effect, especially in pneumonia 
and tuberculosis. 

Damp, cold, and fatigue perhaps precipitate 
the pneumonias, provided one of the infective 
agents be present. The environments that pre- 
cipitate tuberculosis constitute a problem as yet 
unsolved. Very much is widely believed, and 
even more is freely taught, concerning this sub- 
ject, but the evidence is tangled and often con- 
tradictory. 'Toor ventilation,'' dust, dampness, 
etc., have all been accused, but very little has 
been proved concerning the real factors actually 
at work or their mode of operation. In the other 
infectious diseases the effects even of extremes of 
the above factors are but rarely definitely recog- 
nizable. One thing, and one thing only, is abso- 
lutely established, namely, that tuberculosis, pneu- 

*The terms contagrious and infectious were formerly 
carefuUy used and carefully disting-uished. Modern 
writers, however, fail to find any useful or basic sig- 
nificance in "contagious" as contrasted with "infec- 
tious." Hektoen, in Osier's "Modern Medicine," dis- 
cards "contagious" and "contagion" entirely. 

In these articles "infectious" is used to mean "trans- 
missible" or "communicable." 

16 



monia, and the other infectious diseases will devel- 
op under almost any circumstances if the dose 
of infection be large enough, virulent enough, or 
sufficiently repeated. Tuberculosis, pneumonia, 
and the other infectious diseases v^ill not develop 
under any circumstances w^ithout such infection. 

Hence it must be evident that the sine qua non 
of all infectious diseases are their respective 
agents, and that, since the chief sources (infec- 
tive persons) of these are knov^n, the most logi- 
cal efforts are those which concentrate on the pre- 
vention of the dissemination of these agents from 
these sources. 

This is tenable, not only in theory, but in prac- 
tice, and presents an infinitely simpler adminis- 
trative problem than that presented by the older 
hypotheses, — not only in the minor infectious dis- 
eases, where these principles have been practically 
accepted by all, but even in tuberculosis itself. 

Thus, if ''general environment'' be the great 
factor in tuberculosis, the two million people of 
Minnesota must have each his or her own indi- 
vidual environment brought up to and kept at 
some standard-level designed to maintain each 
individual in his or her own alleged ''highest 
state of health.'' 

If, however, the infectiveness of the disease be 
the great factor, only three thousand people (the 
actively infective cases) need this supervision, 
in Minnesota, and they need it, not for the im- 
provement of their "general environment," but 
merely to prevent them from infecting others. 
This problem, even numerically, is but one seven- 
hundredth the magnitude of the other. Consider 
the utterly impracticable expense and difficulty of 
the State attempting to insure only the four quoted 
factors, — good food, proper temperatures, tem- 

17 



perance, and repose, — to two million people (to 
say nothing of the other ''factors of safety'' called 
for by those who lay chief emphasis on control 
of environment, i. e., abolition of foul air, smoke, 
dust, damp cellars, bad smells, dirty back yards, 
etc.), and contrast with this the expense of State 
supervision of three thousand people merely to 
the extent of confining their infective discharges 
to themselves. 

Further consider that the same official mechan- 
ism which could control the three thousand tuber- 
culous could also handle with but slight expan- 
sion the infectious persons needing supervision 
for the prevention of all the other infectious dis- 
eases, except the venereal, as well as the infec- 
tive tuberculous. Remember also that improve- 
ment of the ''general environment,'' allowing that 
its effective achievement were conceivable, could 
not be expected to have any noteworthy effect 
on most of these other infectious diseases, even 
though it had some on tuberculosis. 

Need any more be said to indicate the supe- 
riority of the new principles as practical business 
propositions, over the old ? The latter would re- 
quire the realization of the millenium and an ex- 
penditure of untold millions ; the former could 
be put into operation in three months, with an 
expenditure of twenty-five cents per head of the 
population. 

The stumbling-block is that the general public 
still believes the teachings of twenty years ago 
concerning environment. These teachings were 
a mixture of the "old-wives fables" of the pre- 
bacterial age, with the early incongruities and 
half-truths of the new "theory" of bacteriology. 

Bacteriology is now an old-established science ; 
but despite the fact that it has changed public- 

18 



health work even more than it has changed medi- 
cine or surgery, — and both of these it has com- 
pletely revolutionized, — the public still clings to 
the belief that public health is a curious profes- 
sion, absorbedly interested in cutting weeds in 
vacant lots (''to prevent epidemics"), in burying 
dead animals and suppressing noisome odors (''to 
prevent epidemics") ; in inspecting plumbing and 
collecting garbage ("to prevent epidemics"). 
The "good" health-officer is he who keeps the 
streets clean and the back alleys neat, and who 
falls into a rapture over a newly whitewashed 
outhouse and into a rampage if a pile of old 
bones is found under the cellar steps. Yet those 
who know better let these ideas alone, or even 
acquiesce in them, "to save trouble." Then it 
is expected that the carefully uneducated, or 
miseducated, public opinion will demand up-to- 
date laws ! Is it any wonder that the public in- 
sists on thinking, acting, and legislating to suit 
the theories of twenty years ago instead of the 
scientific knowledge of today? 

Creeds are often misleading, incomplete, or 
fallacious ; yet the temptation to formulate the 
new principles briefly is strong, because their in- 
telligent presentation to the public is so vital. 
Such formulation is attempted here. 

a. Sources of Infectious Diseases 

1. Infectious diseases are infectious because 
they are due to the growth, in the body, of min- 
ute animal or vegetable forms (germs), the trans- 
missibility of these germs from body to body be- 
ing the sole explanation why these diseases are 
"catching." 

2. Wherever in the body the germs develop, 
they leave it chiefly in the discharges, or by 

19 



routes of the discharges, of the nose and throat, 
bladder, or bowel, i. e., from the main orifices of 
the body.* 

3. The discharges infect another person prac- 
tically only when that person takes the discharges, 
in some form, into the mouth or nose, except in 
trachoma and the venereal diseases. "^"^ 

4. Outside the body disease germs do not mul- 
tiply in nature, except perhaps rarely, and very 
temporarily in milk, water, or similar fluids. In 
general, even typhoid bacilli disappear from water 
supplies within two weeks, without evident mul- 
tipHcation. If introduced into milk, most infec- 
tious-disease germs die out as the milk becomes 
acid, generally in a day or- two. Infectious-dis- 
ease germs are rarely found in garbage, and they 
quickly die out if deliberately added. Practical 
modern public health recognizes therefore that the 
bulk of most of the infectious diseases are derived 
directly, or almost directly, from infected persons, 
not much from infected things, except* water, 
milk, food, and flies. The danger from the gen- 
eral environment of an infected person is there- 
fore small. The things in his neighborhood need 
little consideration, except those very immediately 
about him and directly infected by his discharges, 
such as bedclothes, personal clothes, towels, eat- 
ing utensils, and other material objects that may 
receive, and retain for a time, fresh moist dis- 
charges. If attention be efficiently directed to in- 

*This applies to aU the ordinary infectious dis- 
eases m this state. SmaHpox, leprosy, syphilis, and 
some forms of tuberculosis are transferable from skin 
lesions at times. Certain tropical diseases are trans- 
mitted by insects tapping- the blood-stream, etc. Prob- 
ably all infections can be conveyed, as anthrax and 
tetanus usually are, directly by inoculation. But these 
paths are so rare as to be neglig-ible in ordinary life 
here. 

**"Infection is transmitted from an orifice of the in- 
fector to an orifice of the infectee." 

20 



fected persons and their discharges, the general 
surroundings may be safely ignored, except in 
the rarest instances. 

b. Routes of Infcciious Diseases 

5. The routes by which the discharges of the 
sick person pass to the well person are exactly 
those by which the same discharges pass from the 
well person to the well person in ordinary life ; 
for nose and mouth discharges the routes are 
sputum and mouth-spray, conveyed through di- 
rect contact (as in kissing, etc.), and by the 
hands ; for bowel and bladder discharges, the 
hands chiefly ; and for all discharges, the things 
infected by them directly or through the hands, 
especially those things which then go to the 
mouth or touch things which go to the mouth, 
as food, water, eating utensils, tow^els, pipes, 
etc., etc. Flies also furnish an effective route, 
especially to food. Water supplies are peculiar, 
because bowel and bladder discharges en masse, 
in the form of sewage, often enter them directly, 
at times being deliberately poured into them from 
city sewers. 

6. The relative importance of these various 
routes in the carriage of infection varies much. 
The amount and freshness of the discharges, the 
number and virulence of the germs they contain, 
the size and frequency of the dose, and the num- 
ber of susceptible persons who are dosed, must 
always be considered. Almost all the ordinary 
infectious disease germs die out quickly on ex- 
posure to direct sunlight, and fairly rapidly in 
diffuse sunlight. When mucus, feces, and urine 
are thoroughly dried on furniture, door-knobs, 
etc., they are not readily removed again without 
moisture and friction, and when so removed the 

21 



disease germs in them are likely to be dead or 
greatly reduced in recuperative power because 
of the drying. Hence, as a rule, things succeed 
in conveying infection only somewhat directly 
from the infector to the infectee, and practically 
only during the limited period when the germs 
are still fresh and moist. 

c. Control of Infections Diseases 

7. These new principles place at the head of 
official public health activities, the search for and 
supervision of infected persons, and the control 
of the infected discharges, for the purpose of 
excluding them from mouths, and therefore also 
from food and drink. Prompt intelligent disin- 
fection of all the excreta immediately after their 
discharge from the body, is the best w^eapon in 
the supervision of infected persons. Isolation 
of the infected person is the next best, and is 
more universally practicable, because immediate 
intelligent disinfection of discharges can rarely 
be secured outside of the very best hospitals for 
contagious disease. The search for and super- 
vision of mildj early, convalescing, unrecognized, 
and concealed cases and carriers, as well as of 
frank cases, is necessarily an essential item in 
the scheme. 

8. The modern public-health department re- 
quires experts, but not experts in municipal house- 
keeping, in street-cleaning, garbage-disposal, 
smoke-prevention, etc. Its experts are the vital 
statistician, the epidemiologist, the laboratory 
man, and the sanitary engineer, the latter dealing 
chiefly with the broad questions of water-supply 
and sewage-disposal. 



Chapter III 
NON-INFECTIOUS DISEASES 

SPECULATIONS 

The previous chapters indicated that so far as 
the infectious diseases are concerned, the great 
pubhc-health fallacy of the 19th century con- 
sisted in the devotion of nearly all the effort to 
man's surroundings ; of almost none at all to man 
himself. We know now that the sources of in- 
fection are in man; that the routes of infec- 
tion are the routes of man's discharges; and 
that the discharges are harmless until they enter 
man again. It is true that when the infective 
agents reach their goal the resistance of the indi- 
vidual, pitted against the injurious powers of the 
infective agents, decides whether or not actual 
disease develops. But this resistance of the indi- 
vidual is not to be measured by his surroundings : 
it is intrinsic in himself. Alterations of intrinsic 
resistance do, of course, constantly occur, but 
the factors of those alterations are not, as a rule, 
to be readily ascertained. We think that great 
extremes of malnutrition, temperature, and so 
forth may ''depress" resistance. We have evi- 
dence that the smoke nuisance, poor ventilation, 
or smells from slaughter-houses do not. In 
brief, granted sufficient exposure to infectious 
disease, the susceptible individual will succumb, 
though he live in a palace ; the immune individ- 
ual will escape, though he dwell in the slums. "^ 

♦Tuberculosis has long- been held an exception to 
this rule. But tuberculosis was also long" held as (a) 
non-infectious and (b) hereditary, as well as (c) a re- 
sult of certain surroundings. We have reversed (a) ; 
we have reversed (b); we may yet see good reasons 
to modify (c). 

23 



The outcome of the 19th century environ- 
mental doctrines was the binding of heavy bur- 
dens of routine administration concerning sur- 
roundings upon health departments. Results : 
garbage disposal, a polytechnic trade ; street- 
cleaning, a scientific profession ; plumbing, a fine 
art ; and the supervision of infection, a dubious 
and usually a temporary ''job." 

We have pursued chimeras; pursued them in 
good faith of course, but chimeras none the less. 

Suppose now that we admit our errors and 
give to the supervision of tuberculosis,"^^ which 
we do understand, one-half the effort we have 
given to the supervision of ventilation, which 
we do not understand. Suppose, in brief, we 
really organize and really operate a real ma- 
chine which really does reduce, even promises to 
abolish, the infectious diseases. Will it be a sur- 
render of our birthrights for a mess of pottage 
if we forego the chasing down of loose paper 
on the streets and the cleaning up of rubbish piles 
on vacant lots, to turn our attention solely to 
the ''mere abolition of infection''? Are there not 
activities contributing to health beyond these 
limits? Surely, yes; and some of them are 
things that should be done at once without wait- 
ing for that "mere abolition" to be accomplished. 
For example, everyone knows that the bodily 
welfare of mankind does not by any means hinge 
wholly on the infectious diseases. True, the 
abolition of these diseases means also the aboli- 
tion of their immediate sequelae, — sometimes 
as in measles, more harmful than the original 
attack, — and of their remote sequelae, the per- 
manently injured kidney and the permanently 
weakened lung. But even so, a full half of our 

**To say nothing- of syphilis, gonorrhea, summer 
diarrhea, and the rest. 

24 



medical diseases and much more than half of 
our surgical diseases would still remain ; more- 
over, merely to remove disease is not to solve the 
whole problem of securing health in its true 
sense, i. e., the highest physical efficiency pro- 
longed for the greatest period of time. 

THE GENERAL PROBLEM 

The chief of the many phases of disease and 
health are best shown by a parable : 

As a new automobile is accompanied by de- 
tailed instructions for its care and operation, so 
the new small citizen should be accompanied by 
detailed instructions for his care and operation 
when he, a delicate and complicated machine, 
indeed, first appears on the scene. This knowl- 
edge is now accumulated by his parents chiefly 
from experience (which, remember, are his ex- 
periences) or by picking it up at random from 
the neighbors over the back-yard fence. 

Again : As a new automobile is searched so- 
licitously for missing or defective parts, to be 
solicitously and immediately made good before 
the machine is sent out to run against competi- 
tors on the highway, so the new small citizen 
should have at least his sight, his hearing, and 
his breathing tested before he begins the in- 
evitable compulsory-education race against all 
comers on the public highway of the pubHc 
schools. But further : As the most initially per- 
fect automobile, most skillfully run, will yet, as 
time goes on, meet accidents, develop internal 
disruptions, and require repairs, so the new small 
citizen, despite early care and early correction 
of defects, will need supervision and repair all 
through his life, at school and afterwards. 

The parable must end here, for automobiles 

25 



present no affections analogous to infectious dis- 
eases. This very fact, however, brings out more 
clearly the crucial distinction between man as a 
machine and man as a subject of infection. As 
a machine, he may be efficient or inefficient, well 
operated or ill operated, and this all quite apart 
from the existence of actual defect or disability. 
Contrariwise, as a machine he may suffer initial 
defects or encounter accidents or develop internal 
disruptions, all quite apart from his intrinsic 
efficiency or inefficiency and quite apart from the 
skill with which he is operated. But as a subject 
of infection, man is merely a soil more or less 
well suited to the growth of certain small plants, 
or animals. ''' 

The most valuable production of the state is 
its citizens, and the state exists only to insure 
life, liberty, and the pursuit of happiness to them. 
As the automobile maker insists, for his own sake, 
on (a) giving instructions and (b) correcting 
defects ; so the state should, for its own sake, (a) 
instruct parents and (b) remedy children's de- 
fects, perhaps also the defects, disabilities, and 
diseases of adults. Certainly, every state should 
provide at least — 

Education for parents in the personal hygiene 
of children, i. e., the care and operation of 
their children's bodies as machines ; and educa- 



*The fact that in their growth these Uttle invaders 
from without "mess up the works" and make trouble, 
as much as would disruptions originating- wholly 
from within, should not conceal the radical difference 
between the sources and causes of defects, disabilities, 
and non-infectious diseases on the one hand, and of 
the infectious diseases on the other. The former may 
develop in any mechanism; the latter only in those 
mechanisms which furnish a suitable soil for the 
growth of the extraneous invaders. To prevent the 
former the machine must be well built and of the 
best stock, must be scrupulously watched for defects, 
must be constantly overhauled, and must be cared for 
and operated in the most skillful manner. To prevent 
the latter the mere exclusion of the invaders is all- 
sufficient. 

26 



tion also for children in the physical care of 
themselves. 

Supervision, not only for the mere detection, 
but also for the remedy, of initial defects, 
and should provide this early in life, certainly not 
later than the beginning of the compulsory-edu- 
cation course. 

Supervision of children at least throughout 
school-life for the detection, and remedy, of such 
defects, disabilities, or diseases as may develop 
during that period.* 

The supervision of infectious' diseases. 

THE PRESENT SITUATION 

But of all the manifold duties of the state to 
the citizen, only one of those which can be clearly 
shown to bear directly on his bodily welfare, has 
been as yet really recognized fully here — only one 
rests on definite precedent authorization and or- 
ganization, the supervision of infectious diseases. 
The personal hygiene of the citizen {apart from 
the infectious diseases), and the remedy (even, 
until lately, the mere detection) of his defects, 
disabilities, or non-infectious diseases, have been 
regarded (except in the case of the pauper, the 
criminal, or the insane) as of little or no interest 
to anyone but himself. And this, notwithstand- 
ing that all his material surroundings, and all 
his relationships, business and social, have been 
of acknowledged interest to the state from time 
immemorial. 

Why this apparent negligence? First, because 
material surroundings are property, and prop- 
erty has always had precedence over persons in 
almost every relation ; second, because, in the 

*It is difficult to see strictly logical reasons why 
such supervision should end with school-life. Ger- 
many and England are experimenting with the medi- 
cal supervision of adults. 



special relation to disease, the old public health 
taught that the citizen was a result of his sur- 
roundings, and even in the infectious diseases 
this fallacy ruled, as has been abundantly shown. 

Of course, the state is concerned with man's 
surroundings and relationships. It must consider, 
plan for, and carry out measures for his com- 
fort, convenience, safety, pleasure, and happi- 
ness, as well as merely for his health. The state 
exists to do for its citizens co-operatively, hence 
economically and authoritatively, all those neces- 
sary things which the individual could do only 
by great sacrifices or perhaps not at all. But to 
believe that the securing to the individual of 
every possible advantage in all directions is the 
duty of the state, is not necessarily to believe 
that every item of this program should be car- 
ried out by health departments. To hand over to 
any one subdivision of the government control 
both of man and of his surroundings, would be 
to hand over to it all the functions of govern- 
ment. At once, subdivision of these activities 
woulcj be necessary and these subdivisions would 
necessarily pattern after those of the present 
government. Hence such a ''readjustment'' would 
merely replace existing governments, not add to 
their existing efficiency. 

The secret of successful organization is the 
parcelling out along natural lines oi all the dif- 
ferent activities which are to be co-ordinated to 
one great end. It is upon the shrewdness with 
which the subdivision into logical natural groups 
is done that the securing of smoothly-running 
co-ordination depends. Certainly, one most logi- 
cal grand division of any government would be 
that which should deal with man apart from his 
surroundings; and one most logical subdivision 

28 



of that unit should deal with his bodily welfare 
as distinct from his mental, moral, or other wel- 
fare. 

Using the automobile parable for guidance, 
such a ''Commission on Bodily Welfare" should 
deal with — 

Item 1. The education of every citizen in per- 
sonal hygiene. 

Item 2. The supervision of every citizen for 
detection of defects, disabilities, and disease. 

Item 3. The treatment of every citizen for all 
defects, disabilities, and diseases detected. 

Item 4. Finally, that function to which the 
automobile analogy does not apply, i. e., the su- 
pervision of that small group of citizens, the in- 
fectious persons. 

How closely do we in Minnesota approximate 
this ideal ? 

Proper education of every citizen in personal 
hygiene {apart from the infectious diseases) is 
scarcely even foreshadowed by existing efforts. 

Medical supervision {apart from the pauper, 
the criminal, and the insane) is limited to a 
small portion only, of the school children only, 
in a few cities only; and does not pretend to 
remedy'defects, but only to detect them."^ 

Treatment of disease {except for the pauper, 
the criminal, and the insane) is a matter of pri- 
vate purchase or of private philanthropy, usually 
the private philanthropy of the private practicing 
physician. 

The supervision of infectious persons is alone 
really established, authorized, or organized as 
a recognized duty of the state throughout the 

♦About two-thirds of the children of tlie state live 
and attend school in rural districts where medical 
supervision for defects is hardly yet even contem- 
plated, 

29 



state, and then only so far as the protection 
of others is concerned. We have not yet reached 
the treatment of the sick even though they be 
sick of infectious disease. 

But the mechanism for even this function, al- 
though it is actually in existence, actually organ- 
ized, actually authorized, actually operating, and 
has behind it long years of legal precedence and 
the support of public opinion, is sadly under- 
manned, and under-equipped, — merely a skele- 
ton. 

IMMEDIATE POSSIBILITIES 

It is true that even those advanced states which 
have organized, in part or in whole, the abcve 
outlined operations, organized the control of in- 
fectious disease far earlier and more completely 
than they organized any of the others. They 
havd done so in accordance with a general rule, 
which governs all mankind, namely, that of doing 
first the simplest, crudest, and most obviously 
necessary thing. 

But it is also a matter of fact that the super- 
vision of infectious persons differs essentially in 
principles, methods, object, extent of applica- 
tion, and destiny from education in personal 
hygiene, medical supervision for defects, or medi- 
cal treatment. The latter are obviously, directly, 
and immediately to and for the benefit of the in- 
dividual who is educated, supervised, or treated. 
In principle, they are gifts of the state to 
its individual citizens. But the former is not 
to the benefit, usually rather to the temporary 
detriment, of the individual who comes under its 
operation. Its benefits are wholly to others, and 
even so do not add anything to their welfare, 
but merely prevent subtraction from it. 

The methods of the infectious-disease super- 

30 



visor are necessciHly those of the detective ana 
the poHceman, not those of the educator or the 
physician. The object he seeks is prevention, 
not construction or even repair. He does not deal 
equally with every citizen for that citizen's good, 
as does the educator or the physician, but he fer- 
rets out a few individuals who must be restrained 
for the good of the others. His destiny is, if 
successful, to eliminate the only reasons for his 
own official existence, while the educator and 
the medical supervisor for defects will always 
continue to find in each new annual crop of chil- 
dren a new and constantly increasing field for 
their services. 

in brief, the first three activities are, like 
boards of public works, constructional in essence. 
Supervision of infection is like the work of fire 
departments, conservative merely. 

But although we may accept these four items 
as entirely proper for ultimate realization, we 
must acknowledge that the present public-health 
situation cannot be met merely by handing this 
outline to the state and asking that it be put into 
efifect. Still less can it suffice to hand the out- 
line over to existing boards of health or health 
departments, notwithstanding that these consti- 
tute, by tradition and precedent, practice and or- 
ganization, that arm of the government to which 
has been assigned the only activities of the state 
in relation to bodily w^elfare, so far seriously or 
widely recognized. 

Health departments in general are under- 
manned, under-equipped, continually distracted 
with futilities- But if expanded, their distrac- 
tions eliminated, and their faces set sternly to 
the reduction of disease and death, they could 

31 



not at once assume all the items of this program. 
Why? 

Item No. 3 we may dismiss from consideration 
at present. It is out of the question for many 
years to cgme. 

For Item No. 1 the basic necessities, — knowl- 
edge, authority, and organization, — are all lack- 
ing. For Item No. 2 knowledge, authority and 
equipment can be had, it is true, although they 
may not be immediately available. For Item No. 
4 only have we now all three, — knowledge, au- 
thority, and equipment, although the latter only 
in outline. 

EDUCATION 

Furthermore, it is true that Item No. 1, the 
education of every citizen in personal hygiene, 
cannot be carried out properly (apart from the 
infectious diseases) by any organization at the 
present time. 

Why? Because such education requires, first, 
the knowledge, digestion, and formulation of the 
facts to be taught; and, second, the training of 
those who are to do the teaching. 

But the best of us do not know personal hy- 
giene (apart from the infectious diseases) ; that 
is, we do not know how to care for and operate 
the human body as a machine. What, for in- 
stance, should be taught concerning diet when 
Chittenden of Yale and Wiley of Washington 
promulgate exactly opposite views? What should 
be taught concerning ventilation when the whole 
subject is in absolute chaos? What should be 
taught concerning clothing, sleep, exercise, and 
fatigue ? 

Our physiologists study the normal body, but 
more in relation to disease than to health. Our 
vital statisticians seek the factors of morbidity, 

32 



not of physical perfection. Even the famous 
Federal ''poison squad'' sought to determine 
what is bad for people to eat, not what is good 
for them. All of these things are, of course, use- 
ful, excellent, even essential to know ; but they do 
not teach us personal health, they teach only the 
avoidance of actual disease. 

The truth is, that, as regards human bodily 
welfare, personal hygiene proper, we know but 
one factor, that is disease. We know disease be- 
cause we have studied it. We know also the 
"personal hygiene" of farm animals because we 
have studied the "personal hygiene" of farm 
animals, at a cost of twelve million dollars a 
year. But we know nothing of the personal 
hygiene of human citizens, because w^e do not " 
study it at all, except the hygiene of infants. 
We shall never know the personal hygiene of 
humans, apart, always, from the infectious dis- 
eases, until we do study it — until we put as much 
time, pains, and money into it as any agricultural 
experimental station in any state puts into the 
study of the "personal hygiene" of cows and 
hogs. 

There is, however, no real reason wdiy health 
departments should teach personal hygiene at 
all, apart from the infectious diseases, any more 
than that they should teach personal morals or 
personal finance. Health departments have no 
jjeculiar knowledge of the one any more than of 
the others ; and if they had, there are profes- 
sional teachers much more competent and pos- 
sessing far greater facilities than any health de- 
partment. 

Even education concerning infectious diseases 
is not strictly health-department work. This, 
like personal hygiene, should be taught seriously 



and systematically in the public schools. Ninety 
per cent of the population never enter high 
schools, and only one per cent reach the univer- 
sity. Whatever of personal hygiene or preven- 
tion of infection the citizen should know .nust 
be taught in the grades or miss its mark. No 
amount of desultory pamphleteering or lecturing 
by health departments can ever take the place of 
properly conducted, grade courses. Unlike 
courses in personal hygiene, about which we know 
next to nothing, courses in the prevention of 
infection could be established at once, since we 
know almost all about it; but it is no part of 
health-department work to conduct such courses. 
Health departments are police bodies, not preach- 
ers or teachers. They may well, it is true, edu- 
cate the educators. There is no reason why they 
should educate the public, except the failure of 
the professional educators to do so. 

MEDICAL SUPERVISION OF SCHOOLS 

Medical supervision of school children, so far 
as it deals with defects, deals with non-trans- 
missible conditions. Medical supervision, so far 
as it deals with infection, deals with transmis- 
sible conditions. The latter therefore detects 
links in the chain of the ramifying threads of 
infection throughout the community, — a ramifica- 
tion, the threads of which unquestionably should 
be in health-department hands. 

But medical supervision for infectious disease 
in school as a means for general control of all 
infections has had a singularly exaggerated im- 
portance attached to it. Only one-half of the 
state's children attend school in any one year, 
and even the school child passes but one-ninth 
of each year in school. Were health depart- 

34 



ments alert in their familiarity with, and effi- 
cient in their control of, the ramifications of the 
chains of infection outside of the scliools, they 
worM locate and supervise the infective child 
befox , not after, he had infected school chil- 
dren ; before, not after, the medical supervisors 
for defects discovered him in the class-room. 

But the fact that medical supervision for de- 
fects need never encounter infection in that one- 
fourth of the total population which is contained 
in the schools, if health departments do their 
work properly in the other three-fourths which is 
outside of the schools, carries, alas, no guarantee 
that infective children will not, for a long time to 
come, occupy a share of the medical school 
supervisors' attention. Especially will this be 
true in rural districts where nearly two-thirds 
of the children secure their education and where 
health-department organization and equipment is, 
practically speaking, non-existent. 

Hence, whatever may be our individual views 
with regard to the ultimate relation of medical 
school-supervision for defects to supervision of 
infectious persons, we need not blind ourselves 
to the fact that ideal conditions are far in the 
future, and that immediate necessities call for 
immediate adjustments which may be temporary 
or not, depending on future developments. 

Medical supervision for defects and medical 
supervision for infection are now, and, for some 
time to come, must remain, so interdependent 
that the closest co-operation, even, in the rural 
districts, amalgamation, will be necessary. Such 
amalgamation should be under health depart- 
ments, wherever that is possible, rather than 
under school boards. 

First, because school boards have no authority 

35 



from tradition, by precedence or by law, as have 
health departments to follow, outside of the 
schools, the ramifications of infection of whicli 
the infective child in the schools constitutes but 
one link, nor even to follow that one link back 
to its home. 

Second, because school boards have no infor- 
mation or authority concerning the full half of 
the children who are not of school age nor con- 
cerning any adult except those directly connected 
with the schools. 

Finally, amalgamation in the rural districts is 
essential for one great reason, if for no other, 
and this reason is that if we do not combine 
both functions in one, in the rural districts, we 
shall not secure either function there at all. 

SUMMARY 

Non-infectious diseases, disabilities, and de- 
fects constitute a field for governmental atten- 
tion as great as or greater than do the infectious 
diseases. 

There are no theoretical reasons w^hy govern- 
ments should not concern themselves with the 
greater (the non-infectious group), as well as 
with the lesser (the infectious group). 

Public-health activities in their very broadest 
conception would include all the functions of 
government, since there is nothing of interest 
to man, from high finance to municipal play- 
grounds, which has not some relation to health. 

But an administrative system so vast as to 
control all human activities related to health, 
would merely replace the government, and would 
itself be necessarih' subdivided, much as exist- 
ing governments are now. 

It is not difficult to outline a logical program 

an 



for one branch of any government, a branch 
which should deal with the bodily welfare of man 
and include hygienic education, medical super- 
vision, medical treatment, and the suppression of 
infectious diseases. 

But there are many practical, as well as theo- 
retical, reasons wdiy health departments will not, 
indeed cannot, proceed at once to put this pro- 
gram into execution. Concerning education in 
personal hygiene, apart from the infectious dis- 
ease, agreement as to the basic facts to be taught 
has yet to be reached. As to the second and third 
items, organization, broad precedent, and broad 
authority are all lacking. 

Concerning the infectious diseases, and con- 
cerning them only, are the paths clear and the 
duties plain. 

The "instant need of things" is to do faithfully 
and w^ell that one duty which w^e fully under- 
stand, the only one for which organization, au- 
thority, tradition, precedent, and the support of 
public opinion are already in our hands, i. e., the 
abolition of infectious diseases. To this end, the 
embryonic beginnings of the medical supervision 
of every citizen — that is, medical school-super- 
vision — should lend its aid, Especially in the rural 
districts. 

But until we have accomplished this — the sim- 
plest, easiest, crudest of our obvious and recog- 
nized duties— that one which lies right at our 
finger-tips, w^e cannot very w^ell ask that the 
Nation should hand over to health departments 
all its great problems of life, death, health, and 
national development. 

To achieve the abolition of infection we must 
strip for action, discard all useless armor and 
antiquated weapons, cease desultory bombard- 

37 



ment at leisurely long range of the enemy's out- 
lying domains, and personally seek, with well- 
shortened weapons, the enemy himself (infec- 
tion) in his real stronghold (the infective per- 
son). 



3S 



Chapter IV 
THE OLD PRACTICE AND THE NEW 

EPIDEMIOLOGY 

The previous chapters were designed to clear 
the way for the constructive program which the 
following articles will seek to set forth. 

The conclusion so far reached is that the 
chief immediate duty of official public health is 
the abolition of all the infectious diseases. For 
this great enterprise, both scientific principles 
and scientific practice are essential. The new 
public health principles have been outlined; the 
new public health practice remains to be ex- 
plained. 

Public health practice in handling infectious 
diseases may be traced through three distinct 
eras : past, present, and future. 

Past, or era of ''general sanitation/' — The 
practice consisted in a strenuous campaign of 
''general cleaning up" ; an orgy of sweeping, 
burning, scrubbing; an ecstacy of dirt-destruc- 
tion, individual, household, municipal."^ 

♦The reader is begged, pleaded with, besought, not 
to repeat at this point the wearisome old gibe, Then 
you want us to live like pigs? If not, why do you 
condemn "general sanitation?" We do not condemn 
"general sanitation," or cleanliness, or order, or de- 
cency. We simply present the scientific fact that these 
things do not greatly prevent, nor does their absence 
produce, infectious diseases. They have a thousand 
advantages, but not this one. Honesty does not pro- 
tect against lightning; yet this fact can not affect a 
single honest man, nor does its statement detract from 
honesty in the least. And so with "general sanita- 
tion." It is specific, not "general," cleanliness that 
prevents infection. 

39 



This "general sanitation" was a true old-style 
shot-gun prescription used indiscriminately, for 
any outbreak of any disease. No distinction of 
sources from routes of infection was made; in- 
deed, that a distinction existed was hardly rec- 
ognized, and, looking back, it sometimes seems 
that even the most obvious relations of cause and 
effect often were ignored. 

Present, or era of ''specific sanitation/' — The 
practice is deliberately to analyze the particular 
outbreak of the particular disease concerned; 
speedily to determine thus the exact route of in- 
fection actually responsible; and promptly to 
abolish or block that route. 

Future, or era of ''supervision of sources:' — ■ 
The practice, so far as it is possible to forecast 
it, will be the location and supervision of the 
sources of infection (infected persons) before, 
not after, they gain access to routes, so in time 
eliminating infectious diseases entirely. 

Thus it is seen that public health practices, 
past, present, and future, form a series, descend- 
ing from the general to the particular, from the 
surroundings to the individual, from (a) the 
random application of blanket measures, through 
(b) a specific detection and a specific correction 
of a specific bad condition, to (c) the actual fore- 
stalling of the development of such conditions at 
all. 

COMPARATIVE METHODS 

To make clear this most important matter of 
-public health practice, illustrations are oft'ered, 
exhibiting the public health practices of the 
different eras in action in the face of a typhoid 
fever epidemic, typhoid being selected because 
abolishing this one disease alone involves every 

40 



modern public liealth principle, and, in some 
form, every modern pul^lic liealth practice. 

The end sought was, is, and always will be, 
the same, — to stop the spread of the disease. 

But the methods of the different eras contrast 
widely. 

In the past era of ''general sanitation," a ty- 
phoid epidemic w^as met by a vigorous attack on 
dirt, damp cellars, dust, disorder ; on garbage, 
manure, dead animals, weeds, defective plumb- 
ing, and stagnant pools ; cobwebs were cleared 
away ; windows were opened to -"let in the blessed 
sunshine" ; preachers preached cleanliness ; teach- 
ers taught bathing ; health officers limed back 
alleys and whitewashed outhouses. Human na- 
ture demanded ''action,'' and "action," of a kind, 
was supplied. 

We know now, what they did not know then, 
that typhoid infection is carried by water, food, 
flies, milk, and contact, and that "general clean- 
ing up" could not remove infection from pollut- 
ed water-mains, or purify a contaminated milk 
supply ; could not stop the eating of infected 
food or eliminate contact infection. ^^ The only 
form of typhoid which ''general sanitation" 
could greatly affect was that due to flies. t But 

♦Contact infection is the infection which radiates 
directly from the infected person through nose and 
mouth and bladder and bowel discharges. The hands 
of the infector and of his associates are the chief car- 
riers of all these discharges, although mouth-spray 
and sputum also act in many diseases. Things directly 
infected by these discharges are also dangerous, but 
practically only while the discharges remain fresh and 
moist. The radius of action of contact is usually 
small; it compares with the radius of action of water, 
food, flies, and milk somewhat as a bayonet with a 
gatling gun in a general melee. But contact infection 
in the long run is more deadly than other routes, for 
to each one such "gatling gun" there are many 
"bavonets." 

tWe do not now use "general sanitation" even for 
fly outbreaks. From this old shot-gun prescription we 
have eliminated all the ingredients but one, that one 
which alone was active. In fly outbreaks "vv^e exclude 
flies from infected discharges, and (so far as the pri- 
mary outbreak is concerned) then stop. So does the 
outbreak. 

41 



of course the fly was not then known as a route 
of infection in typhoid, so that even the results 
that ''general sanitation" secured were secured 
largely by accident, i. e., by the unknown con- 
junction of an unrecognized cause with an un- 
premeditated cure. 

The present era of ''specific sanitation" began 
a decade or so ago. Water, food, flies, and milk 
have been fully recognized as the main public 
routes of typhoid infection; contact, especially 
of late, as the great private route. Outbreaks 
have been met by finding the particular route 
involved, and by abolishing or blocking that 
route. But even in this era, the earlier practice 
for the attainment of this end diflfered funda- 
mentally from that of today. 

The earlier epidemiologistsf of this era ar- 
gued thus : "Water, food, flies, and milk are 
the known public routes ; usually some one of 
these routes is responsible in each outbreak. 
Therefore, to find the responsible route in any 
given instance, flood the stricken community 
with trained inspectors ; analyze the water sup- 
plies ; investigate the milk supplies ; go through 
the markets; delve into the provision stores; es- 
timate the number of flies, and locate their breed- 
ing-places ; survey the back alleys and out-door 
toilets ; plat all results on maps ; interview the 
city engineer, the fire marshal, the meat and 
milk inspectors, and examine their official rec- 
ords ; secure the morbidity and mortality records 
of the board of health ; study all available me- 
teorological, topographical, geological, and oth- 
er data ; in brief, probe, dissect, tabulate, collate, 
and compare all possible physical information 
concerning the community. Under such inquisi- 

tExperts on epidemics. 

42 



tion the guilty route of infection can scarcely 
escape detection." 

For these methods it must be said that they 
were scientific, logical, and exhaustive; but they 
were terribly laborious and generally exceeding- 
ly slow. Of course it sometimes happened that 
the guilty route of infection was stumbled on 
at once ; and almost always this end was reached 
sooner or later, too often, however, only after 
weeks, months, or even years of effort. Their 
ponderous slowness took these methods out of the 
class of effective emergency measures, and this 
was recognized even then, for typhoid investiga- 
tion was not considered a matter of haste, in 
initiation or in execution. 

These earlier methods paralleled somewhat 
those which we might suppose an amateur hunt- 
er to use, if he were commissioned to find a cer- 
tain sheep-killing wolf. Confronted with this 
problem, the amateur might, not unreasonably, 
flood the surrounding mountains with assistants, 
instructing them to find all the existing wolf- 
trails, and to follow each such trail inward 
towards the slaughtered sheep until satisfied that 
it did, or did not, actually lead to them. 

The methods of today are the exact converse 
of these. Instead of finding in the mountains 
and following inward from them, say, 500 dif- 
ferent wolf trails, 499 of which must necessarily 
be wrong, the experienced hunter goes directly 
to the slaughtered sheep, finding there and fol- 
lowing outward thence the only right trail, — the 
only trail that is there, — necessarily the trail of 
the guilty wolf. 

THE NEW EMERGENCY EPIDEMIOLOGY 

The epidemiologist of today, called to a ty- 
[ hoid-stricken community, at first pays no at- 

43 



tention to the physical condition of the existing 
possible routes. It is sociological data, not 
physical, that he needs at this stage. He knows 
that, counting the wells, the toilets, the milk 
supplies, etc., there may be 500 of these possible 
routes ; but he does not go to see them, nor even 
the pumping-station or the sewage-outfall. He 
goes, hot-foot, straight to the "slaughtered 
sheep" — straight to a patient's bedside. There, 
in thirty minutes, he reduces the 500 possibili- 
ties to, say, 10, i. e:, to those encountered (a) 
by this paticjif'^ (b) at a certain time (the date of 
his infection). These 10 are carefully listed; 
but the epidemiologist does not investigate even 
these 10. He goes, instead, straight to another 
bedside and lists there the, say, 10 routes that 
constitute the possible routes for this second pa- 
tient ; but he does not investigate the routes on 
this list either; he merely compares the two lists. 
Why? Because the one guilty route must be 
on both lists. Thus if both lists show the same 
water supply, that water supply remains a pos- 
sible guilty route; but, if not, water is eliminat- 
ed. If both lists show^ the same milk supply, 
that milk supply remains a possible guilty route ; 
but, if not, milk is eliminated. Discarding thus 
the routes not common to both lists, 5 routes, 
say, still remain. At the third patient's bedside 
these 5 are reduced by similar treatment, to say, 
3. So the search goes on until he either locates 
the one main public route common to all or 
proves that the outbreak is not due to such a 
public route at all, but to the private routes ex- 
tending directly from person to person, i. e., to 
contact. Often in twelve hours of such work, 

*Of course imported and secondary cases are not 
used for this purpose, and at this stage the epidemi- 
ologist is most careful to eliminate all such from his 
tabulations. 

44 



jL;cncrall\ in twenty- four, almost always in tliirt\- 
six, the e\ idcncc is a^nclusixc. I1ic i^uiltx' route 
stands out convicted ; for it is found on every 
list, and the innocent routes are exonerated, for 
they occur only on some.* 

Now, at last, and not till now, does the epi- 
demiologist deal directly with the route of in- 
fection thus indicated, examine it to find just 
how it is responsible, and thus provide the ini- 
tial data for its remedy. f 

It is at the point when the guilty public route 
is shown (if pubHc route there be) that the 
epidemiologist, so far as this public route is con- 
cerned, steps out, and the bacteriologist, the 
chemist, the sanitary engineer step in ; one, or 
any two, or all three, as conditions may require. 

But detecting and demonstrating the guilt of 
a main public route, w^hen such is involved, by 
no means ends the epidemiologist's duties. The 
work outlined so far is required (in Minnesota) 



*Obviously this method fails if there be but one 
patient, for then comparison of lists is of course im- 
possible; but single cases usually prove to be imported 
or from contact. Also it may happen that even three 
or four patients do not furnish sufficient data to nar- 
row the possible routes to one; obviously, the more 
patients there are the more conclusive the results. 
But even when only a few patients exist, this method 
reduces the number of routes to be investigated to 
say, 10, often to 2 or 3, an immense reduction from the 
original 500. 

tTo those who are not familiar with modern public 
health work, this account may seem incredible or at 
least exaggerated, yet these are the regular proce- 
dures of emergency epidemiology wherever they are 
understood today. Records of such work in Minnesota 
for years back are open to all enquirers. Moreover, 
the above account has pictured the epidemiologist 
working under a most disadvantageous condition, i. e., 
in complete ignorance of the community he deals with, 
except for what he learns during the investigation it- 
self. If previous familiarity with the affected com- 
munity exists, the main public route of infection can 
often be determined without leaving headquarters, 
provided merely that correct data as to the number, 
location, and dates of infection of the cases are sub- 
mitted. Of course such "long-distance epidemiology," 
wonderfully accurate though it -can be made, does not 
compare in reliability or in finish of detail with actual 
personal investigation on the ground. 



chiefly in typhoid outbreaks ; and then chiefly 
in those typhoid outbreaks which are derived 
from water, food, flies, or milk. * The work still 
to be done is required in all typhoid outbreaks, 
whether initially derived from these public routes 
or from contact ; moreover, it is called for in the 
majority of outbreaks of all the other infec- 
tious diseases, because the majority are usually 
contact outbreaks at all stages. That work is 
the prevention of further spread by contact. 

To understand this clearly, it must be re- 
membered that under present conditions every 
typhoid, or other, epidemic which begins from 
some one public route (water, food, flies, or 
milk) soon presents two distinct parts ; the pri- 
mary outbreak, consisting of those persons who 
received their infection from that public route, 
and the secondary outbreak, consisting of those 
persons who later, by the private routes of con- 
tact, receive their infection directly from the first 
set. Those typhoid, or other, epidemics which 
begin from the private routes of contact do not, 
of course, present a ''primary" outbreak at all. 
They are, so to put it, "secondary" outbreaks 
from the outset. 

The search for a public route is therefore only 
the first step in subduing any epidemic. If such 
route exist, this step, by finding it, provides for 
getting rid of it, which prevents the infection of 
any more persons from that route, and so ends 
the primary outbreak. But this first step by no 
means ends the epidemic as a whole, for the per- 
sons already infected from that public route con- 
stitute each one a source of further spread by 
contact, a spread which, of course, must also be 
prevented. Obviously, epidemics which are con- 
tact epidemics throughout, necessarily present 

46 



an identical problem from this standpoint, for 
every existing infected person, whatever the 
route of his infection, is a separate danger, and 
each requires supervision.*" 

FINDING THE UNKNOWN CASES 

How does the prevention of contact infection 
depend on epidemiology? Cannot the spread of 
infection by contact from knozvn cases be guard- 
ed against by the attendants (nurses and physi- 
cians) which each such knozvn case necessarily 
has? True, and were these known cases the 
only danger-points proper attention to prevent- 
ing spread from them would be all-sufficient. 
But the knozvn cases usually form but half of 
the danger-points because only half of the dan- 
gerously infected persons become knozvn cases. 
The other half consists of ''missed cases" (mild, 
unrecognized, and concealed cases, early cases, 
and, later on, convalescing cases) and of ''car- 
riers.'' (The "carriers" are infected persons, 
capable of infecting others, but not themselves 
made ill by the disease germs which they never- 
theless carry and distribute.) 

Missed cases and carriers, unless especially 
sought for, are, and remain, unknown and unlo- 
cated ; they have no known attendants to whom 
the prevention of spread of infection from them 

*In earlier days the faHacy that typhoid fever pa- 
tients could not directly infect their associates — in 
brief, that typhoid fever was not contagious — was re- 
sponsible for the long--delayed recognition of second- 
ary typhoid outbreaks, even after the origin of pri- 
mary outbreaks had been learned and methods of deal- 
ing with them perfected. We know now that abolish- 
ing or blocking a primary route is but half the story. 
The primary cases, if neglected, may continue to in- 
fect other persons by contact, and these again others, 
ad infinitum. Such secondary outbreaks may extend 
slowly for months or years and yield cases equaling 
or exceeding in number those from the primary out- 
break. The "endemic typhoid" of some localities is at 
times an unrecognized, slow-moving, secondary out- 
break. 

47 



can be entrusted ; they ^ienerally do not know 
themselves to be infected; and, if ignored, they 
are more dangerous, because inevitably un- 
guarded, than the known cases, for, being 
known, the latter can be guarded. 

This problem, the finding of missed cases and 
carriers, is solved by an epidemiological proce- 
dure which, while less spectacular, is far more 
widely ♦useful than that of finding public routes, 
because it applies, not alone to contact-typhoid 
outbreaks, but to all contact outbreaks, that is, to 
all infectious diseases, from tuberculosis down. 
Were the ability to find public routes of infec- 
tion in water, food, fly, and milk outbreaks the 
only virtue of epidemiology, its services could 
have no value in the great mass of infectious dis- 
ease for the great mass arises chiefly by con- 
tact. It is the ability to find the private sources 
of infection in contact outbreaks that makes 
epidemiology the pivotal factor of modern pub- 
lic health. 

This location of missed cases and carriers in 
typhoid, and other, outbreaks, is called concur- 
rent epidemiology, and is well worth thoroughh' 
understanding. 

SUMMARY 

Modern public health practice for the control 
of infectious diseases consists, not in the physi- 
cal surveillance of whole communities, but in 
the sociological study of the infected persons in 
them. 

This practice is best illustrated in t\\e modern 
handling of typhoid, fever epidemics, because 
this disease is all-inclusive, i. e., it travels by all 
four of the great public routes (water, food, flies, 
and milk), as well as by the private fifth route, 

48 



contact; also because typhoid is an intestinal in- 
fection and, of all the infections diseases of the 
temperate zone, the intestinal infections alojte 
travel by all of these five great routes. 

A typhoid epidemic is approached, as is any 
other epidemic, first, to determine if any public 
route of infection is involved, and, if so, what 
that route is and how it operates, thus finding 
how to stop it; second, to determine the private 
routes and sources of the contact outbreak which, 
sooner or later, exists in all epidemics, whether 
the original route be a public route or not. 

To the epidemiologist, the public health de- 
tective, falls both these crucial tasks. It is his 
function to find those underlying facts which 
alone can form a sound basis for real remedial 
measures. 

How he performs the finding of public routes 
has been described ; the finding of private routes 
and sources will be described later. In both 
procedures the initial step is the same, namely, 
the investigation of the known cases. By seeing 
and questioning known cases, or their imme- 
diate relatives and attendants, the epidemiologist 
can classify them into native and imported. The 
native cases, since they alone originated in the 
community under investigation, are further clas- 
sified into primary and secondary cases. From 
the histories of the primary cases, if such there 
be, he learns the public route. From all the 
cases, imported, primary, and secondary, he ob- 
tains the data needed for the next step. 



49 



Chapter V 
THE NEWEST PRACTICE 



The preceding chapter outlined the first step in 
the modern handling of a typhoid fever epidemic, 
typhoid fever being selected because its proper 
handling illustrates best the principles and practice 
of modern public health work. 

The first step is the discovery, by the methods of 
emergency epidemiology, whether water, food, flies, 
milk, or contact be the original main route of infec- 
tion. The second step, to be outlined in these 
pages, is the location, by the methods of concurrent 
epidemiology, of all the infected persons (known 
cases, missed cases, and carriers). These are lo- 
cated because each, regardless of the original route 
by which he himself became infected, forms a new 
center of infection for spread by contact. 

It was further pointed out that neither emergency 
epidemiology nor concurrent epidemiology were 
limited in their application to typhoid fever; and 
that the ability of concurrent epidemiology to handle 
properly contact typhoid outbreaks, whether con- 
tact be the secondary or primary route, is a con- 
clusive demonstration of its ability to handle all 
other infectious diseases, since these others, while 
spread by public routes to some extent, are, in the 

♦Emergency epidemiology is the epidemiology re- 
quired in outbreaks from single great routes, — water, 
food, flies, milk. Concurrent epidemiology is the epi- 
demiology required in contact outbreaks, i. e.. out- 
breaks from multiple private sources. Emergency 
epidemiology is rapid and spectacular; it is played 
hard, against time, to save large groups of people. Con- 
current epidemiology is relatively slow and plodding; 
it ferrets out, one by one, the individual persons whose 
infection threatens families or small groups. Emer- 
gency epidemiology will disappear when the great 
routes are properly protected. Concurrent epidemi- 
ology will greatly develop; it is the most powerful 
and practical weapon yet devised for the abolition of 
the infectious diseases. 

50 



mass, contact infections chiefly. No dependence on 
the argument by analogy from typhoid fever to 
other diseases is needed, however; for these other 
diseases are now^ and have been for years past han- 
dled successfully by these very methods. 

Most persons contemplating the problem of 
finding missed cases and carriers for the first 
time, pronounce it impossible; then suggest, as 
the only solution, a house-to-house canvass of 
the whole community, hastily adding that of 
course such a measure is quite impractical. As 
a matter of fact, the public health detective does 
at times use, and use successfully, exactly that 
"impractical" measure, — the house-to-house can- 
vass. This house-to-house method is used in pri- 
mary outbreaks from public routes, to locate un- 
reported primary ''known cases," and also to lo- 
cate primary missed cases and carriers. It is 
necessary in such primary outbreaks because the 
distribution of primary missed cases and carriers, 
as well as of "known cases," is co-extensive with 
that of the guilty route. There is no other guide 
to their location, and therefore the whole distri- 
bution of the guilty route must be searched. But 
the need of such a canvass of a whole community 
arises here only in typhoid or other infec- 
tious intestinal outbreaks; and then only when 
the infection is spread by a route common to the 
whole community, and therefore practically only 
when the guilty route is a public water supply. 
In milk outbreaks, those who did not use the 
guilty milk need not be examined ; and a similar 
statement is true also regarding food outbreaks. 
Fly outbreaks rarely affect a whole community un- 
less the community be very small ; and in small 
communities of course a general canvass is not 
difficult. 

In the majority of epidemics, and because the 

51 



majority of epidemics are due, not to great pub- 
lic routes, but to private contact, the finding of 
missed cases and carriers does not require even 
a partial house-to-house canvass. This is true 
of typhoid, and other, sccojidary outbreaks 
(which are contact outbreaks) as well as of the 
great majority of all outbreaks (since the ma- 
joritv are contact outbreaks only. 

The reason why missed cases and carriers can 
be found in contact outbreaks without a house-to- 
house canvass depends upon a fact of which the 
true significance is not fully appreciated outside 
of epidemiological circles. It is this : such missed 
cases and carriers are not distributed at pure, 
blind random anywhere and everywhere through- 
out the community. They occur hi certain 
groups — and these groups can he located because 
they betray themselves through their connection 
with known cases. Hence the location of knoivn 
cases locates these groups also."^ 

This most important epidemiological principle 
is called the principle of zones of infection. It 
is the cardinal principle of concurrent epidem- 
iology. 

The principle of zones of iiifection was first 
clearly recognized in diphtheria epidemics, and 
its development and demonstration as a practical 
working rule depends, primarily, on diphtheria 
investigations ; but both principle and practice 
have now been established for all the well-studied 
epidemic diseases. 

*It must not be supposed that these groups are con- 
fined to families, immediate neig^nbors, etc. Their true 
basis is sociological relationship, not mere pliysical 
propinquity. In a single scarlet fever outbreak origi- 
nating in one community Dr. A. J Chesley found the 
related sociological groups distribu>:ed in 3 states, in- 
volving 3 cities. 2 villages, and 24 townships in 10 
counties. The Mankato typhoid fever outbreak of 1908 
affected over 40 points outside of Mankato. 

52 



The cpidemiolo£^ist,t in putting this principle 
into practice, locates first the known cases, and 
then searches the zones of infection, which they 
indicate, for missed cases and carriers. The de- 
tails of this search vary with each disease and 
are too technical for consideration at this time. 
Detective methods are used, illuminated by ex- 
pert technical knowledge of each disease, its 
natural history, and the methods of recognizing 
it, laboratory and clinical, at every stage and 
under all disguises. Suffice it to say that the 
finding of missed cases and carriers, as well as of 
known cases, — that is, of the very framework of 
the ramifying threads of the infectious disease, — 
is a problem not only solvable, but. already 
solved, and already reduced to a routine basis. 
As an art, this concurrent epidemiology is some- 
what more arduous and time-consuming than the 
art of emergency epidemiology, but it is thor- 
oughly practical and has been successfully fol- 
lowed for years past all over this state, in an 
average of tw^o to three epidemics every week. 
The visiting nurse in ''concurrent epidemiology,'' 



tit must be evident that those private practicing" 
physicians who are not health officers, cannot, for 
many reasons Tvell understood by the profession, do 
epidemiological work, emergency or concurrent, ex- 
cept in overwhelming outbreaks, where ordinary con- 
ventions and social relations are temporarily foregone. 
Even those private practicing physicians who are also 
health officers, encounter difficulties and obstructions, 
ethical, social and conventional, which professional 
epidemiologists, Tvho are not in private practice, do 
not meet. Hence in all outbreaks the physician finds 
that his most valuable functions consist in treating 
the sick and in advising protective measures to those 
who apply to him. Physicians also often combine, 
very successfully, to publish material or give public 
lectures of instructions during epidemics. But, after 
all, the chief service "which the physician can render 
to official public health is the reporting of kno^vn 
cases. Known cases, as has been shown, are the basic 
datum-points for emergency epidemiology, i. e., for 
the finding of the routes of infection; and they are 
even still more important in concurrent epidemiology, 
i. e., in the study of the zones of infection. Epi- 
demiology is greatly aided when the physician per- 
forms thoroughly this, his nrimary. public health duty. 

53 



can be made a most valuable and efficient aid, to 
say nothing at present of the other and even 
more indispensable services in other directions 
which are within her especial province. 

This principle of zones of infection applies to 
tuberculosis just as to any other infection spread 
by contact; indeed, the location of missed cases 
in tuberculosis (carriers in tuberculosis are hypo- 
thetical to date) offers less difficulty to modern 
epidemiology than the same problem in other in- 
fectious diseases. 

FUTURE APPLICATIONS 

So much for past and present practice. 

Turning now to the future era of ''supervi- 
sion of sources,'' the principles and practice al- 
ready described pave the way for appreciation 
of the probable developments. In reconsidering 
the wolf metaphor already outlined, everyone 
will ask, and wisely, Why wait until some sheep 
are killed before we protect the others? Why 
not patrol the known routes by which the wolves 
reach the sheep; or, better, build wolf-proof 
folds; or, best of all, teach the sheep to protect 
themselves — to fight the wolves or at least to 
dodge them? 

Those who believe that infectious disease can 
be warded off, in the face of infection, by diet, * 

*A most important exception to the g-eneral state- 
ment that proper diet in itself cannot prevent the de- 
velopment of infection provided infection gains ac- 
cess to the body should be recorded to cover the case 
of nursing" infants. It has long- been noted that breast- 
fed infants, during the period that they are so fed (but 
during that period only) are, practically speaking, im- 
mune to many infectious diseases. This is so true of 
scarlet fever and measles, that in such diseases no 
great concern need be felt for such an infant, even 
though the mother herself have the disease. In diph- 
theria, a nursling to some extent shoves a like im- 
munity. In smallpox, this is not true and in tuber- 
culosis it is at most very doubtful. 

That this escape of nurslings is purely a matter of 
the enormous advantages in nutritional value, to an 

54 



"exercise, good ventilation, and ^'strict observ- 
ance of the laws of bodily health/' are those 
who would train the sheep to fight ; would train 
the body to destroy all infection that may reach 
it. But, as we do not know how to teach sheep 
to fight, so we do not know the laws of health 
needed for this purpose if any such exist. f 
Such methods tested against infection have gen- 
erally failed^ so far. In that day when sheep 
fight wolves they may succeed. Those who be- 
lieve that the sheep may be taught to dodge the 
wolves have much more in their favor. 

Dodging infection is well understood. The 
physician, the nurse, the epidemiologist, handle 
with impunity the very sources of infection 
themselves, — infected persons and their infect- 
ed discharges. Why not teach this art to every 
citizen? The principle is simple, — prevent in- 
fected discharges from entering the mouth. It 
is in the practising of this principle, simple as 

infant, of mother's milk over other foods has yet to 
be demonstrated. Nursing- infants are by the mere 
fact of nursing- less likely than are other infants to 
be exposed to whatever routes or sources of infection 
may be about, unless the mother is herself a source. 
But in scarlet fever and measles, at least, this is not 
the whole explanation. It has been suggested that the 
real reason lies in the transmission to the child of 
actual immunity-producing bodies in mother's milk. 
If this be so, breast-feeding" in infants as a protection 
ag-ainst certain infectious diseases combines in one 
operation three principles of defense; good nutri- 
tion, specific immunization and the avoidance of in- 
fection. Other forms of feeding fail to provide these 
defences; and usually combine against the infant poor 
nutrition, absence of immunization, and exposure to 
the five routes of infection. Great skill and care and 
constant watchfulness may serve in artificial feeding 
partially to offset these dangers; breast-feeding auto- 
matically protects against them almost without effort. 
Moreover, breast-feeding accomplishes in other ways 
four times the service in saving infant's lives that it 
accomplishes in cutting out infectious diseases. (The 
writer wishes to record his indebtedness to Dr. J. P. 
Sedgwick, of Minneapolis, for much valuable informa- 
tion on this subject.) 

tOnce more we beg our readers not to think that 
because building up the body cannot make it proof 
against infectious diseases, building up the body 
should be abandoned. To say that physical care of the 
body never made a Newton or a Shakespeare, is not to 

55 



it is, that the inexperienced person fails. A 
single slip may be fatal, and slips are constantly 
made. Moreover, to guard against those infect- 
ed persons who are not recognized as such, 
means that all discharges must be kept out of all 
mouths at all times, — a theoretically possible, but, 
to the vast majority of the work-a-day world, a 
practically wholly impossible, performance. If 
we give up in despair the hope of excluding all 
discharges from all mouths and attempt to teach 
the ordinary citizen to recognize infection so that 
he may avoid at least infected discharges, we 
shall be attempting to make of each citizen, man, 
woman, and child, a highly trained physician. To 
teach personal defense against infection is a 
great thing for those who learn and practice it. 
As a general method for abolishing infectious 
diseases, it is quite hopeless ; nevertheless, each 
citizen should have the chance to learn at least 
the principles. 

Those who believe that infectious disease 
should be warded off by specific immunization" 
have some sure ground to go upon; but the 
scope of immunization is at present small. These 
are they who would build wolf-proof folds ; but 
we do not know how to build folds which will 
be proof against all kinds of these wolves. It 
is true we know how to build a fold which is 
proof against smallpox, and that is vaccination. 
Also we are experimenting with a fold proof 
against typhoid, which is antityphoid inoculation. 
But, alas, granting such folds are built, driving 



say that no man should care for his physical welfare. 
The laws of physical health, even so little as we know 
of them, have many virtues. Because protection from 
infectious diseases is not one of them detracts no whit 
from any of the others. 

JTuberculosis and pneumonia are often held ex- 
ceptions to this rule, but that they are exceptions is 
being- questioned. 

56 



the sheep into them is a procedure forbidden to 
pubhc health, except in Germany. In vaccination 
and in antityphoid inoculation the old adage still 
applies : ''First catch your sheep." 

Those who belieye in guarding routes of in- 
fection are those who would patrol the ap- 
proaches to the sheep. This is at least a pos- 
sible method, already established as of great val- 
ue in some diseases. But a consideration of the 
following table shows that, like immunization, 
its scope is limited. Its scope is broader than 
that of immunization, but it is not broad enough 
to cover all infectious diseases. 

If we tabulate the different infectious diseases 
occurring in the temperate zone on the basis of 
their chief routes of transmission we find that 
w^ater, food, flies, and milk are the main public 
routes ; the many private routes we group under 
contact; not every route operates in every dis- 
ease. Thus : 

The Chief Infectious Diseases of the Temperate 

Zone Classified by Their Chief Routes 

of Infection 

Typhoid fever (and oth- 
er intestinal infec- 
tions) are carried 
chiefly by water food flies milk contact 

Tuberculosis (human)* 

is carried chiefly by flies** milk contact 

Diphtheria, scarlet fev- 
er, measles, German 
measles, mumps, 
w h o o p i n g-c o u g h, 
smallpox, chickenpox 
are carried chiefly by milk contact 

Syphilis, gonorrhea, 
trachoma, cerebro- 
spinal meningitis, 
leprosy are carried 
chiefly by contact 

♦Bovine tuberculosis is of course derived chiefly from 
the milk of tuberculous cows. In many ways this dis- 
ease is best separated for administrative purposes 
from human tuberculosis. The carriage of human 
tuberculosis in milk referred to in the table is that 
dependent on the infection of milk by tuberculous 
milk handlers. 

♦♦Insignificant. 

57 



Hence water and food as great public routes 
of community infections carry only the intes- 
tinal infectious diseases. Flies, practically speak- 
ing, also carry this group only, the amount of 
tuberculosis carried by flies being small. Milk 
carries many infectious diseases, but contact 
alone carries all. 

If we guard water supplies only against in- 
fection, we eliminate water-borne intestinal in- 
fections (this, so far as typhoid is concerned, 
would be about one-third of the total typhoid in 
Minnesota). We leave untouched intestinal in- 
fections carried by food, flies, milk, and contact. 
Also we leave untouched all other infectious dis- 
eases,"^ If we guard food, as well as water, we 
eliminate such intestinal infections as are car- 
ried by food and water, but the fly, milk, and 
contact routes for these remain ; so do all routes 
which carry the other infectious diseases. 

If we eliminate flies also, fly typhoid and its 
congeners go, but milk and contact typhoid 
still remain with us. It is true that a slight ef- 
fect on tuberculosis also might be noted, but 
nothing else is touched. If we guard milk sup- 
plies against infection, f we begin to make great 
strides, but contact, the great route of human 
tuberculosis and of all the other infectious dis- 
eases, including the intestinal (in Minnesota), 
still will operate. 

The fact is that while public water, food, fly, 
and milk infections parallel invasion by wolves 
coming from zvithoiit, contact infection parallels 

*Hazen's theorem — that infected water suppUes 
carry aU the infectious diseases — is an unproved and 
much disputed hypothesis as yet. 

tA great deal of the alleged milk supervision of 
today to prevent watering or to keep up the fat stand- 
ard has no relation whatever to guarding milk against 
infection. Even the campaign for clean milk elimi- 
nates dirt chiefly. Unless especially conducted to pre- 
vent infection, it fails on this latter score completely. 

58 



the presence amongst the sheep themselves, of 
"wolves in sheep's clothing." Such wolves, 
because intermingled with the- sheep, cannot pos- 
sibly be eliminated by guarding the approaches. 

If, then, the guarding of public routes can 
exclude only some of the infection, what re- 
mains? 

The extermination of all the zuolves — the 
abolition of the sources of infection. 

If our modern wolf-hunters can find the un- 
disguised wolves and even the wolves in sheep's 
clothing, after the sheep are slain, w^hy cannot 
they find them also before the sheep are slain? 
If the very sources of infection (known cases, 
missed cases, and carriers) cannot escape our 
epidemiologists armed with their modern princi- 
ples, why wait for an epidemic before we go 
after them at all? 

Turn again to the table and see that if we 
begin operations for control with water, we 
must move through food and flies and milk to 
contact before we have included all even of 
typhoid; and until we reach contact, we do not 
begin to touch the bulk of the other diseases 
at all. But if we begin with control of con- 
tact, we find that the method zvhich eliminates 
contact infection necessarily eliminates the other 
forms also. That method when shorn of non- 
essentials is the supervision of all infectious 
persons. 

THE NEW PROGRAM 

To drop metaphors, the new program of of- 
ficial public health is the abolition of the in- 
fectious diseases. 

The measures for this purpose in progressive 
order of general efficiency, from lowest to high- 
est, are — 

59 



1. The securing to each individual citizen 
continuously of his highest possible general 
physical health. Tdeal as this is as an end in 
itself, it can have little effect on most infectious 
diseases, except indirectly during infancy, al- 
though it is supposed to be a factor in reducing 
tuberculosis and pneumonia even in adults. 

2. The securing to each individual citizen of 
instruction and training in the personal conduct 
which he must follow in order to avoid receiv- 
ing into his body the discharges of infected 
persons. This as a system is perfect, but tlie 
securing of the daily carrying out by everyone 
of the personal conduct needed is a hopeless 
dream. 

3. The securing to each individual of con- 
tinuous specific immunization. Technically prac- 
tical as yet only against smallpox and typhoid 
fever by inoculation, and in infancy against cer- 
tain infections by breast-feeding, the scope of 
this procedure is very limited ; and it must be 
remembered that the public have never yet 
adopted even smallpox immunization, except 
under compulsion, to an extent sufficient to abol- 
ish even this one disease. 

These three measures place the abolition of in- 
fection directly upon the individual, as though, 
to abolish foot-pads, we should arm each citi- 
zen and train him in jiti jitsu; or as though, 
because of one free wolf, we should put five 
hundred sheep in armor. The three measures 
which follow place the abolition of infection di- 
rectly upon a very small group of experts who 
deal directly with the infection itself. These 
three measures would put the one wolf in bonds, 
and let the five hundred sheep go free. 

4. The physical supervision of the four great 

60 



public routes of infection (public water sup- 
plies, public food supplies, flies, which are pub- 
lic property, and public milk supplies) to ex- 
clude all discharges from them. The principles 
are well understood, but, in practice, systematic 
application usually is lacking. (Physical super- 
vision of such public and private surroundings 
as, by their effect on conduct, may bear on the 
operation of the fifth and greatest route of all, 
i. e., contact, is necessarily at present more a 
matter of education than of official action, espe- 
cially where private surroundings are involved.) 

5. The physical supervision of all knozvn in- 
fectious cases to exclude their infected dis- 
charges from all routes. This, thoroughly done, 
would make a tremendous impression on infec- 
tious diseases. But known cases form not more 
than half the sources of infection. 

6. The sociological supervision of all infec- 
tious persons. These are the sources of infec- 
tious disease. Once found and supervised, infec- 
tion from the human must stop in toto. 

For the first three measures, education, dem- 
onstration, persuasion, are the things required; 
but also the abolition of carelessness, poverty, 
and the pressure of necessity. Knowledge alone 
is not enough ; time and facilities to do with 
are needed also. To supply all these to every 
citizen, man, woman and child, is an ideal to 
be sought by every path ; but an ideal that will 
take long years to realize. 

For the second three we have principles and 
practice, precedent, authority, some law, and the 
hearty support of public opinion in epidemics. 
We need a few new laws. Chiefly w^e need 
proper organization and increased equipment; 

61 



but, more than all, the hearty support of public 
opinion, continuously ^ not in epidemics only. 

Of all these measures, the last is certainly 
the most inclusive ; properly done, it excludes 
the need (so far as abolition of infectious dis- 
eases is concerned) of all the others. It is 
cheaper, simpler, easier, more direct and rapid 
than any other, and does not ''interfere" with 
every citizen, in every act of daily life, indefi- 
nitely, for it deals with but one small class (in- 
fected persons), and only while infective; and 
it deals, even with them, merely to the extent 
of preventing the spread to others of their infect- 
ed discharges. 



62 



Chapter VI 
INDIVIDUAL DEFENSE 

PUBLIC DEFENSE AND PRIVATE 

The preceding chapter distinguished sharply 
those things necessary to escape disease, which 
individuals may do, from those things necessary 
to prevent disease, which communities must do, 
because individuals cannot. 

The present chapter will outline the former. 
As already indicated, these individual efforts 
may be made in three directions : 

1. To secure high general physical health. 

2. To secure specific immunity to specific 
diseases. 

3. To avoid disease, especially infectious dis- 
ease. 

Efforts in the first direction would aim to build 
up and make palaces of the bodies in which we 
dwell and which, too often, are mere hovels ; but, 
alas, the palace burns as easily as the hovel. It 
would be futile to seek the physical advancement 
of the race in order to abolish disease. We should 
seek the abolition of disease in order to physically 
advance the race. 

THE PREV^NTABILITY OF THE "^PREVENTABLE"'' 

DISEASES 

True, we should not await this abolition be- 
fore seeking general physical advancement, but, 
unfortunately, we know as yet few practicable 
rules of general application, except for infants, 
to achieve such physical advancement. Far bet- 

63 



ter than how to secure high physical health we 
know how to avoid disease, at least, how to avoid 
certain diseases. A few of these are non-infec- 
tious environmental diseases, like scurvy and 
miner's elbow ; and the non-infectious poisonings, 
like the poisonings from lead, arsenic, phos- 
phorus, alcohol, and illuminating gas. These dis- 
eases depend upon readily recognized mechanical 
or physical surroundings. A change of diet in 
scurvy or of position in miner's elbow ; stopping 
leaks in pipes for illuminating gas poisoning ; re- 
fusal to admit the other poisons to the body — 
and all are abolished. These non-infectious 
poisons furnish but 1 in 1,000 of all deaths, 
except in infancy, where non-infectious intestinal 
poisonings furnish a large proportion. 

On the other hand, the poisonings which are 
infectious, i. e., the infectious diseases, furnish 
more than one-sixth of all the deaths, and about 
one-half of these deaths are from one infectious 
disease, namely, consumption. Like the chemical 
poisonings, — lead, arsenic, etc., — the infectious 
diseases depend on noxious materials that enter 
the body. But, unlike lead, arsenic, etc., the 
poisons which produce the infectious diseases 
are associated, not with a few well-known ma- 
terial surroundings and inanimate things, but 
with the living activities of many, often unknown, 
persons. 

The little we know of how to achieve high 
health, and the much more we know of how to 
avoid disease, should be taught our 2,000,000 
citizens of Minnesota. This huge task requires 
a mechanism so huge that only our huge public 
school system can accomplish it.* 

*It is often said that practising" physicians should 
teach healtli to the public. In one sense this is true. 
Physicians represent medicine, and medicine deals 

64 



Efforts in the second direction (for specific im- 
munization) would aim to ''fireproof" our bodies 
against disease, whether those bodies be "pal- 
aces" or ''hovels." But such fireproofing can as 
yet be done only against smallpox and typhoid 
fever. "^"^ 

Also, just as the general public will not fire- 
proof literal houses against literal fire, despite 
large fire losses every year, so the general public 
will not fireproof their bodies against infection, 
even against smallpox. One hundred years of 
vaccination has left us in Minnesota with only 
30 per cent of children under 16 years of age 
protected against smallpox. AVe shall be lucky 
if 10 years of antityphoid inoculation finds us 
with 10 per cent of adults protected against ty- 
phoid. In the absence of compulsory laws, rig- 
orously enforced, immunization must remain a 
task of systematic education, reaching everyone, 
and this task also only the public school system 
can properly perform. 

Efforts in the third direction would aim to shut 
out all poisons, including all infections, from 
all bodies, w^hether these bodies be palaces or 
hovels, on the principle that as no dwelling, pal- 

with disease, its cure, and its prevention. But prac- 
tising engineers might as weU be drafted to teach 
geometry as practising physicians to teach personal 
hygiene. Physicians dealing with their own patients, 
or even lecturing or writing on these subjects, do 
much good. Such work, however, is but a drop in 
the bucket, reaching only a fraction of the public and 
generally just that fraction which needs it least. 
There are over 2,000 practising physicians in Minne- 
sota. They have not time, training, organization, or 
authority for the sort of teaching that will really 
reach all citizens; the public school system has all 
four, and 15,000 teachers to do it with. 

^Medicine must furnish the facts that are to be 
taught, but it is quite impossible that practising phy- 
sicians should do the teaching. 

**The immunity possible against diphtheria through 
protective doses of diphtheria antitoxin, is too short- 
lived for general continuous application to all citi- 
zens. 

65 



ace, or hovel can burn if fire do not reach it, so 
our bodies, good, bad, or indifferent, cannot be 
destroyed by disease if the causes of disease be 
shut out from them. To abohsh Hteral fire from 
Hteral dweUings is impracticable, for fire is too 
useful for abohtion. Disease serves no useful 
purpose, and its abolition is the only reasonable 
goal. 

The exclusion of the poisons of disease, in- 
fectious or non-infectious, from the body, is the 
most successful preventive measure we have 
at present against most diseases that are prevent- 
able at all. The methods should be taught to 
every citizen ; and for this again the public school 
system alone is able. Public health experts must 
supply the facts; it is quite impossible that they 
should do the teaching."^ 

''dodging infection'' 

Dodging infection rests on simple principles, 
already outlined. The one essential is to exclude 
from entrance to the body, matter from infec- 
tious bodies ; i. e., in briefest practical form, for 
all except the venereal diseases, to exclude from 
the mouth the infected discharges of others. 

To do this requires, first, the ability to recog- 

*Of each 1,000 school children in Minnesota schools, 
450 leave school at the end of the 6th grade work, 450 
leave at the end of the 8th grade. The remaining- 100 
enter the high school; but only 50 gjaduate. Ten put 
of the 1,000 thousand enter the University; 5 gradu- 
ate. We now teach in the earlier grades theoretical 
anatomy and theoretical physiology, intending- thus 
to form foundations for later practical information. 
Since 90 percent of children leave at the 8th g-rade, 
this 90 percent receive the theoretical information 
only; they never learn its practical use at all. 

This system needs inversion. We should teach the 
practical parts of hyg-iene and of avoidance of 
disease to the 100 percent of children; i. e., not later 
than the 6th grade, leaving the theoretical parts for 
the 10 percent that take the higher courses. 

The State Superintendent of Education, Mr. C G. 
Schulz, authorizes the statement that he is making- 
plans to have these subiects taught in the public 
schools in the manner indicated, just as soon as ar- 
rangements can be made. 

66 



nize infectious persons ; and, second, the skill 
to avoid their discharges. But we cannot teach 
the general public, half of them children, to rec- 
ognize infectious persons. If, then, we broaden 
the rule and teach avoidance of discharges of 
all sick persons, whether infectious or not, we 
ignore those persons who are infectious without 
being sick. Hence, for the non-medical citizen, 
the rule must run : Exclude all dis.charges of all 
persons from all mouths. But this is by no means 
so easy as it sounds. 

''contact'" 

Mouth-discharges are exchanged in the form 
of mouth-spray, sputum, and smears on various 
things, but chiefly by smears on hands. 

Mouth-spray consists of tiny, often micro- 
scopic, drops of liquid from the mouth, thrown 
out in sneezing, coughing, shouting, singing, and 
speaking, but not in quiet breathing. The larger 
ones can be seen, if watched for, and they can 
be felt falling upon the face in face-to-face con- 
versations. Talk, or sing, or shout, or cough, or 
sneeze against a mirror two feet distant, and 
count the drops that strike it. Then picture to 
yourself what happens at "teas" and ''sociables" ; 
at meals, with lively conversation going on ; at 
school; at church. Think also of what happens 
when the cooks or waiters talk while preparing 
food, cough wdiile laying tables, or sneeze while 
wiping dishes. 

This distribution of mouth-spray cannot be 
prevented unless all wear masks, as modern sur- 
geons do when operating. 

But exchange of mouth-spray may be avoided 
somewhat, by avoiding close face-to-face conver- 
sations, as by sitting: side by side or far apart ; 
by coughing or sneezing always into a handker- 

67 



chief, etc. Often, of course, the cough or sneeze 
comes too quickly or the hands are already full. 
It is true that the head may be turned aside ; but 
often this spares the person in front at the ex- 
pense of others, and, while coughing or sneezing 
into the hand prevents the mouth-spray from 
flying wide, the spray goes to the hand and the 
hand itself passes it on to the other persons later. 

There is no practical method of avoiding all 
mouth-spray of associates, except not to have 
associates ; but the amount of exchange may be 
diminished by the above precautions. 

Sputum, through the spitting habit, falls upon 
floors, steps, sidewalks. That these deposits dry 
and blow about as dust is the least of the dan- 
gers, especially out of doors, for sunlight and dry- 
ing disable most disease germs. Sputum follows 
a much more important route leading to mouths, 
and this route is followed, not when the sputum 
has become dry and dusty, but while it is still 
fresh and moist, — while the germs in it are still 
alive. This route is by way of shoes, directly 
into houses. There, wiped off on carpets, it 
awaits the creeping baby ; it smears itself on the 
baby's fingers ; and he carries it directly into his 
mouth. Also, in removing shoes, the owner of 
the shoes uses his fingers and then, too often, 
the owner's fingers, just like the baby's, enter 
the mouth unwashed. The value of anti-spitting 
ordinances thus becomes apparent. 

But, after all, hands are the great route of 
exchange, and hands furnish the great route for 
bladder and bowel discharges, as well as for nose 
and mouth.* 



*Hands do not carry only infectious diseases. They 
are the chief routes by which lead is carried to 
mouths in lead-poisoning", and are also an important 
factor in phosphorus poisoning-. 

68 



From birth to death those universal tools, our 
hands, g"o to our mouths incessantly ; from birth 
to death we use them for every other purpose 
also. Hands encounter all the discharges of the 
body many times a day; and if not scrupulously 
washed on every such occasion, they carry these 
discharges to everything they touch, including 
other hands, which go to other mouths. The 
very handkerchiefs we advocate to cough or 
sneeze or blow our noses into, transfer these 
same discharges to our fingers, the next time that 
we use them.'^^'''^ 

Then we shake hands wnth others, or feel the 
babv's new tooth, \lsits to toilets, unless fol- 
lowed at once by careful hand-washing, mean 
similar transfer of the toilet discharges as well, 
particularly amongst children, who, remember, 
form half the population. 

The common drinking-cup and the common 
drinking-pail are bad because they help to ex- 
change mouth-discharges; the roller-towel is 
w^orse, especially when used for half-zvashed 
hands, because then it helps to exchange all the 
bodily discharges: but the iinzvashed hands them- 
selves are worst of all, because the discharges 
they carry are undiluted and fresh and moist and 
warm. When strangers enter a household, they 
add, through mouth-spray and hands, their dis- 
charges to the general household stock ; and, 
due to this, harvesting help, threshing crews, etc., 
introduce infectious disease into numerous rural 
families and communities every year. 

Within the purview of the private citizen at 
home, discharges are also exchanged somewhat 
through things soiled by mouth-spray and hands, 

*It has been sug-gested that the left hand should be 
used for handkerchiefs, thus leaving- the right hand 
clean so far as these discharges are concerned. 

69 



as well as directly. Thus are contaminated dishes 
in laying the table, bread, cake, etc., also pillow- 
cases and sheets which are soiled by mouth or 
other discharges from the body. The list of 
the things which may carry such discharges, is 
too long for itemizing here ; but, in general, such 
things do not form really very important routes 
of transfer, except when the discharges are con- 
siderable in quantity and while the discharges are 
fresh and moist. Once dried on clothing, mouth- 
spray, for instance, is not readily set free, and 
when it is dry, infection, if present, dies out with 
fair rapidity. Just as the main public routes of 
discharges from the community to the family are 
public water supplies, public food supplies, public 
milk supplies, and public outdoor flies, so the 
main private routes within the family, apart from 
mouth-spray, sputum, and hands, are private 
water supplies, private food supplies, private milk 
supplies, and private indoor flies. Public sup- 
plies may or may not bring discharges with them 
to the family; once they enter the family, they 
pretty surely receive them from the family itself. 
So also with the private supplies of the same 
things : the family well may or may not be dosed 
with the family discharges ; the family drinking- 
pail or pitcher almost always is ; the family cow 
may or may not contribute discharges to the fam- 
ily milk-pail, but the family milker practically 
always does"^' ; and later, within the family, the 
family milk-pitcher receives the family mouth- 
spray. The family food, before and even after 
cooking, is subject to similar contamination. The 
family flies moving from the outdoor toilet, un- 

*If a milker talks or sings or coughs or sneezes, 
using- a wide mouth pail, his mouth discharges enter 
the milk. If he milks with unwashed hands, all his 
discharges enter the milk also. 

70 



less it be fly-proof, or from indoor spittoons or 
slops to food, aid in the same exchange.'^ 

Knowing these dangers is half the battle won. 
Against infection of public routes, — public water 
supplies, public food supplies, public outdoor 
flies, and public milk supplies, — the private cit- 
izen should not need precautions, for these the 
community itself should guard. But if he need 
them, the private citizen has against such public 
routes two powerful weapons: (a) exclusion 
from his premises of the infected route, and (b) 
cooking. Foods are, of course, usually cooked, 
even in ordinary life ; water may be boiled, milk 
Pasteurized, and if flies cannot be excluded, the 
food they contaminate can be rejected or cooked 
again. 

The public routes of infection are not difficult 
for the citizen to guard against, however onerous 
that guarding may be : the real difficulty is with 
the private routes, the routes of contact that 
carry infection within the family and also within 
the school, the office, the workshop, the factory. 
We, individually or collectively, may abolish in 
time the common drinking-cup and common 

*A curious perversity of human nature makes us 
attach undue importance to many possible but unim- 
portant routes of discharges, like telephone-receivers, 
dirty money, the licking- of postage stamps, etc., Tvhile 
we neglect the commonplace, really important routes, 
acting' daily and everywhere, above outlined. 

An example of the same thing is seen in the great 
anxiety expressed concerning meat as a route of in- 
fection. It seems to be remembered but seldom that 
meat is almost always cooked; i. e., it almost always 
automatically receives the very treatment Tve solicit- 
ously prescribe for blocking infection through milk 
and through water. .Meat-inspection is wholly proper. 
to secure good meat, and to prevent the robbing of 
the consumer's pocket and the consumer's stomach. 
But all the meat-inspection in the world could not 
reduce our ordinary infectious diseases by one-tenth 
of 1 percent. Meat, as food, especially cold meat, often 
carries the family discharges, but disease in, or dis- 
charges attached to. meat from its sources outside the 
family, are in most cases destroyed by cooking. 

71 



roller-towel, but no one can ever abolish mouth- 
spray or hands. "^ 

It is true that by education'^''^ we may greatly 
affect personal conduct, but to leave the abolition 
of infection in ordinary life to the personal con- 
duct of all sorts of people, half of them children, 
would be as wise as to trust the destruction of 
infection in a water-borne typhoid outbreak to 
the boiling of the water by the private citizens. 

♦Two miUion mouths, served by 4,000,000 hands, 
receive 6,000,000 meals in Minnesota daily. But this 
is not as important as are the hands that handle the 
meals in preparation; moreover, hands g-o to mouths 
far more often between meals than during them. 

**The following- rules prepared for use in the public 
schools at the request of County Superintendent Geo. 
S. Selke, Benton County, indicate the main points to 
be taught concerning- protection from infectious dis- 
eases in the schools. They indicate also pretty closely 
what can be done in the home and for this reason they 
are inserted here. 

Placard for Schools 

The g-erms of infectious diseases are in the dis- 
charges of infectious persons. Infectious diseases are 
"caug-ht" from infectious persons simply by taking 
into the mouth some portion, usually very small, of 
their infected discharges. 

The Great Rules of Prevention in Schools. 

1. Exclude from school all infectious persons, thus 
excluding" all infectious discharg-es. 

2. Since infectious persons may enter school at 
times despite the g-reatest vigilance, restrict, so far 
as possible, the scattering of any discharge of any 
person at any time in school. (This will also train 
the children to restrict their discharges out of school 
and in after-life). 

a. Mouth discharges are transferred directly to 
and taken directly from drinking--cups, towels, pencils, 
chewing-g-um, whistles, etc. Mouth, nose, bladder, and 
bowel discharges are transferred directly to hands 
many times daily. Hands g-o to mouths many times 
daily; therefore — 

Provide individual drinking-cups, individual towels, 
individual pencils, individual modeling-clay, individual 
modeling-sand, etc. There should be a sign in every 
school. "Wash your hands after every visit to a toilet." 

b. Sputum (spit) or other discharges, deposited on 
floors, sidewalks, etc., are picked up by shoes and so 
carried into homes. W^hen handling- shoes (putting 
on, taking off, etc.), discharges are transferred to 
hands, which go to mouths, or touch thing-s that g-o 
to mouths. Therefore — 

Avoid depositing- discharges, — sputum, etc., — on 
floors, sidewalks, or elsewhere where other people may 
step on them. 

c. Mouth-spray is thrown out in talking-, singing-, 
coughing-, sneezing-, etc., therefore — 

72 



Avoid throwing- mouth-spray into other people's 
faces by avoiding close face-to-face conversations, 
face-to-face recitations, face-to-face sing-ing-exercises, 
etc. Cough, sneeze, etc., into a handkerchief always. 

d. The air of a schoolroom in use necessarily re- 
ceives mouth-spray into it in talking-, reciting, etc. 

e. Bladder and bowel discharges are carried by 
flies when flies can get at them. During early autumn 
and late spring or summer sessions, flies may carry 
these discharges from toilets to children's lunches, 
etc.. therefore — ■ 

Make toilet-vaults fly-proof. Provide springs or 
weights to automatically close toilet-doors, and fly- 
screens for toilet-windows. 

f. Three things destroy comfort and success in 
school work: Temperature too high; atmosphere too 
dry; air not in motion. Also, no child can work well 
in a poorly lighted room; but do not imagine that 
good lighting, good heating, and good ventilation will 
prevent spread of infection if infectious persons gain 
entrance. No school is a sanitary school if the chil- 
dren exchange their discharges without restriction; 
but only those schools where infectious persons are 
watched for and excluded are safe schools., therefore — 

Note daily the general state of health of each child. 
No child who shows any decided change from the usual 
for that child, especially fever, headache, sore throat, 
stomach-ache, or general dumpishness, should attend 
school until seen by a physician. This rule permits 
early detection of infectious children. It also excludes 
children who should be excluded for their own good, 
even if non-infectious. 

g-. Children showing- defective vision, hearing, 
breathing, etc., should be referred to the principal, 
superintendent, or school board for action. 

All health officers know that adults in large pro- 
portion will not, and children cannot, boil the 
water. Moreover, the law in Minnesota now 
recognizes that the community has no right to 
supply water of such a kind that the consumer 
must protect himself against it. This principle 
should be extended, so that the community is 
held responsible for infection carried by any 
public route, — food, milk, or flies, — as well as by 
public water. Some day the equally logical step 
should follow, — the holding of the community re- 
sponsible for all infectious diseases, by whatever 
routes they travel, including contact. The com- 
munity, thanks to modern science, can abolish 
the sources of all infectious diseases ; and once 
the sources are abolished, the diseases, being non- 



existent, cannot travel by any route, even by 
contact. 

The simple fact is, that the private citizen in 
his own home can protect himself against public 
routes of discharges as just outlined and from 
the family discharges to some extent ; but the 
moment he leaves home and enters into relations 
with the general public, his individual control is 
at an end. He cannot guard, generally he can- 
not even ascertain, the sources or routes of the 
water, milk, food, or flies he must encounter. 
Above all, he cannot guard the sources or routes 
of the discharges furnished by the persons he 
necessarily meets. His children go to school, 
compelled directly by the law to do so, and 
there they share discharges which no personal 
defense through conduct can wholly avoid. He 
goes himself to work, compelled indirectly by 
the law to do so, and there he shares discharges 
which he can little or not at all control. Only 
the community can exclude infection from the 
public routes of discharges, water, milk, food, 
and flies ; but also only the community can ex- 
clude infection from the private routes of dis- 
charges grouped under ''contact." 

Of course, the exchange of discharges already 
outlined, however inevitable, is harmless unless 
and until infected discharges enter into the ex- 
change. The chances of encountering infected 
discharges can be approximated somewhat from 
the supposition that daily there goes at large, 
unknown, about one infective person in each 500 
of the population. Hence, he who would de- 
fend himself from infection by his habitual per- 
sonal conduct toward his associates must avoid 
the harmless discharges of 499 uninfected per- 
sons in order to avoid the harmful discharges 

74 



of one unknown infected person. (This estimate 
is necessarily a guess, and it does not include the 
venereal infections.) 

The great weakness of the personal defense 
through conduct is this : The precise moment 
when it is most needed is the precise moment 
that it generally fails. In the first place, the 
mouth-spray of the ordinary well person is not 
half so abundant or so widely scattered as that 
of the case of tuberculosis, of measles, of whoop- 
ing-cough, or of influenza, for these are just the 
diseases in which coughing and sneezing are 
prominent symptoms. The bowel-discharges of 
the ordinary well person are not half as likely to 
be disseminated as those of the typhoid or dysen- 
tery case, for these are just the diseases in which 
frequent, abundant liquid stools, often involun- 
tary, occur. Again, the discharges of the well 
person are handled chiefly by that well person 
himself : the discharges of the sick must often be 
handled by associates unused to performing such 
services for others. Finally, exactly as green 
troops forget under fire all their parade-ground 
drill, trip over their own feet, and fire into the 
ground or at the sun, so the citizen, however 
carefully he may have practiced a well-thought- 
out system of avoiding discharges in ordinary 
life, goes all to pieces in the flurry when his 
child develops, say, scarlet fever. Of course, 
it is true that green troops soon recov.er their 
parade-ground drill, even in the face of the en- 
emy; but they cannot do what seasoned troops 
can do, and the non-medical citizen can seldom 
protect himself in the face of infection as the 
trained contagious-disease nurse does, the physi- 
cian, or the epidemiologist. Nevertheless, if he 
lias previously known, and practiced even crude- 

75 



ly, the necessary precautions,"^' he is in a much 
better position to defend himself. 

SUMMARY 

The whole subject of public health divides 
itself into — 

1. Securing high physical development and 
efficiency. 

2. Avoiding disease. 

Of the former we know little of practical ap- 
plication to the general population except in in- 
fancy. 

Of the latter we know much of cure, but lit- 
tle of prevention, except in the environmental 
diseases, in the poisonings, as from lead, arsenic, 
alcohol, etc., and especially in the infectious dis- 
eases. 

Defense against environmental diseases and 
the non-infectious poisonings is largely a matter 
of trade conditions and of avoiding dangerous, 
but known, non-living things and therefore 
largely of legislation, inspection, and conduct. 
Against infectious diseases, the sources being 
infected persons, defense is essentially a matter 
of precautions against those persons. The prime 
difficulty is the recognition of those persons. If 
they are not recognized, the defense becomes a 
matter of guarding against all persons. 

Defense against infection may be divided into 
individual and community defense. 

*It is a fatal faUacy to believe in "general cleanli- 
ness" as a defense against infection. It is not the 
"g-eneral cleanliness" of surroundings that prevents 
infectious diseases; it is the "specific cleanliness" of 
freedom from infected discharges. Scrubbed floors, 
bright pans, neatness, and order do not necessarily in- 
volve, usually do not imply, hands free of discharges; 
they cannot stop mouth-spray. A gorgeous uniform 
no more shows ability to shoot than does "general 
cleanliness" show ability to avoid infection. It is not 
visible dirt that hurts. — mud, ashes, coal-dust, — but 
the usually invisible discharges in mouth-spray and 
on hands, and even these only when laden with infec- 
tion. 

76 



Infectious diseases are carried by four main 
public routes — water, food, flies, and milk, and by 
a fifth private route, contact. By cooking all ali- 
mentary supplies before eating them, the public 
routes may be guarded at the consumer's end, 
but public opinion and, in the matter of water 
supplies, the law, rightly demand the transfer of 
this burden of protection to the producer. 

The private routes of contact can be guarded 
by the individual also, but only by a ritual so 
elaborate and covering so general a field that it 
does not adequately meet the ordinary conditions 
of the ordinary life of the ordinary citizen, espe- 
cially of hard-working fathers, hard-driven moth- 
ers and young children. Contagious-disease ex- 
perts, with long, patient training and when deal- 
ing with known infected individuals, generally 
succeed ; the ordinary untrained citizen must very 
often fail. 

Notwithstanding that the community can and 
should assume the prevention of contact-infection 
(by excluding infection from the community en- 
tirely), as well as the care of the four public 
routes, the methods of personal defense should 
be well known to all; and there exists no means 
of teaching them comparable at all with the great 
public school system, for that, and that alone, 
reaches the citizens personally and in detail. 
There, in simple languao:e, all that is useful can 
be readily tauo:ht. and it must be taught in the 
sixth grade, or earlier, to reach the population as 
a whole. 



Chapter VII 
COMMUNITY DEFENSE 

THE PUBLIC HEALTH ENGINEER 

The preceding chapter indicated the hnes of 
personal defense against infectious disease which 
are available to the private citizen for his own 
protection through his own efforts. 

The present and succeeding chapters will deal 
with community defense, — those operations 
which, if properly conducted by communities for 
the good of all, would make unnecessary the 
burdensome efforts of individuals to protect 
themselves. 

The three great community measures for the 
abolition of infectious disease have been listed 
in increasing order of efficiency as — 

1. The protection of all public routes of in- 
fection, public water supplies, public food sup- 
plies, public milk supplies, and public flies. This 
is now done in some places to some extent. Usu- 
ally it is but half done, chiefly for lack of proper 
understanding of what are real protective meas- 
ures, or of proper organization for their exe- 
cution; too often, also for lack of proper men 
to carry them out. 

2. The physical supervision of known cases 
of infectious diseases. This also is often now 
attempted. Indeed it is, on paper, the most de- 
veloped of all. But its efficiency is cut down by 



lack of reporting, concealing of cases from phy- 
sicians, etc., and especially by lack of sufficient 
trained experts in epidemiology to do the close- 
to-the-ground daily work. 

3. The sociological supervision of all infec- 
tious persons, already outlined in previous 
articles. 

The first of these items is dealt with here. 

For the protection of the public routes of in- 
fection three things are needed : proper physical 
construction, to exclude infection ; proper physi- 
cal operation, to maintain this exclusion ; and 
the supervision of the human factor, — ''the man 
behind the gun.'' A locomotive may be built 
perfectly and be kept in perfect running order; 
but the locomotive engineer himself is still the 
soul of the machine. Perfect physical equip- 
ment and perfect physical maintenance of pub- 
lic utilities related to the spread of disease, 
are enormously important, yet they are less im- 
portant than the men who are to be in actual 
control of the actual operations. No better 
illustration of this can be offered than the fact 
that the milk supply from tested highbred cows, 
palatially housed, scrubbed, and vacuum-cleaned, 
has carried disease and death to its consumers, 
because one man engaged in handling the milk 
conveyed infection to it by the intimate personal 
contact which no organization or mechanism can 
wholly avoid. 

Some of the worst water epidemics we have 
ever had were due to the human factor failing 
at the critical moment. This failure of the human 
factor, which is a commonplace in accidents by 
rail or boat, applies equally to all branches of 
public health, although the usual belief is that 

79 



almost any person is good enough to conduct 
public health work. 

The reason for this commonly accepted belief 
is probably that public health work for the pre- 
vention of disease, or for the general physical 
advancement of the race, is often confused with 
certain measures which make merely for ease 
or comfort; and it is human nature to look down 
upon those whose services minister to our com- 
fort. We forget that by our slaves we rise and 
by our slaves we fall. Too often they and their 
procedures are neglected so long as comfort and 
convenience are supplied by them without too 
much trouble to those who enjoy the fruits of 
their labor. 

To define public health engineering in the light 
of the new public health principles, it must be 
defined as such work as deals through the physi- 
cal construction and operation of physical sur- 
roundings and mechanisms with (a) the preven- 
tion of disease or (b) with the advancement of 
physical bodily welfare. If we include also, as 
is sometimes done, all such operations as con- 
duce, however indirectly, to any kind of ''racial 
advancement,'' we must add all engineering 
works, architecture, street paving, acoustic prop- 
erties of public buildings, the size of doorways, 
fire-escapes, bridges, railways, and every other 
form of modern artificial surroundings, and with 
them their corollaries, noise, dust, the smoke 
nuisance, etc. 

The line between true sanitary measures and 
those for securing mere comfort or convenience 
must be drawn somewhere, and it must be re- 
membered that all ''racial advances" are by no 
means advancements of public health. The rail- 
roads are of great sociological importance to the 

80 



race, but they often carry disease where disease 
would not have traveled otherwise. Every ad- 
vance which leads to greater prosperity leads to 
more intermingling of people and to wider social 
relations and so involves a wider exchange of 
bodily discharges. The installation of a public 
water supply system adds great comfort, con- 
venience, decency, and physical welfare, but it 
also provides a route of infection which leads 
directly into every home. If you put all your 
eggs into one such basket, you must zmtch that 
basket. A sewerage system, by getting rid of 
outdoor toilets, greatly conduces to decency, com- 
fort, and cleanliness, and even obviates one dan- 
ger of disease (carriage of toilet discharges by 
flies from the outdoor closet) ; but it also con- 
centrates all those discharges into one foul union 
and the disposal of this often endangers other 
communities. There is no real ad\'ance in trans- 
ferring the burden of infectious disease from one 
community to another by passing the sewage on 
from one water supply to another. Hence the 
true province of the Public Health Engineer is 
not the mere advocacy and construction of great 
engineering enterprises, but, rather, the super- 
vision of the construction of such, to see that the 
public health harm they may do, if the public 
health view be neglected, is properly avoided, so 
far as physical construction or operation may 
avoid it. 

The Public Health Engineer is not therefore, 
or, rather, should not be, merely what the popu- 
lar imagination makes him, a man of sewer pipes 
and concrete; of water-meters, manholes, and 
pumps. The New Public Health Engineer will 
be a man of keen eye to see those features in all 
community construction work which may conduce 

81 



to greater exchange of discharges, a man who 
knows just what is needed for prevention of dis- 
ease in such ways, and therefore can both pro- 
vide proper precautions and at the same time 
avoid unnecessary and expensive precautions. 
The civil engineer has been defined as he who can 
do for $1.00 what any fool can do for $4.00. He 
is a physical economist. He insists on physical 
safety, but zvithin that limit knows best how to 
achieve the needed safety without undue expendi- 
ture. The Public Health Engineer, dealing with 
water supplies, sewage disposal, etc., does just 
this thing. He guarantees sanitary safety, and 
withi7i that limit he guarantees it for less money 
than the ordinary builder. Any keen student of 
infectious diseases can generally see the grosser 
faults in a supply which permit infection. The 
Public Health Engineer is a specialist. He sees 
these faults very much more quickly and surely ; 
if they are obscure he has the skill and knowl- 
edge to disentangle them; and when he finds 
them, he knows how to correct them. . 

The Public Health Engineer is, or should be, 
much more than this, however. He is the only 
public health worker whose initial professional 
training necessarily makes of him a business 
man, in the sense of an administrator of opera- 
tions on schedule time, and with economy of labor 
and expense. Those physicians who make good 
administrators in this sense do so because they 
learn it in administration, not because of initial 
professional training. This training of the Pub- 
lic Health Engineer makes him also the best man 
to supervise maintenance of public utilities, as 
well as to construct and equip them. Further, 
the absence of training in mechanisms and ma- 
chinery so prominent in the training of most 

•82 



health officials, makes of the Public Health En- 
gineer the only public health man who can deal 
properly with the many mechanical devices for 
modern handling of the public routes of infec- 
tion, on the perfection of which many lives often 
depend. The hypochlorite plant, the mechanical 
filter, the Pasteurizing device are machines. 
However well a physician may understand the 
underlying biological principles, he cannot figure 
the pitch of a cog-wheel or find the reason of 
the filter ''loss of head'' without infinite and 
wasteful effort, if at all. 

The Public Health Engineer is in public health 
what the surgeon is in medicine, the ''man of his 
hands,'' — the actual operator. Whatever the phy- 
sician may discover as surgically necessary to be 
done, it is the surgeon who must bring his skill 
and knowledge to bear upon the doing of it. So, 
although the epidemiologist, the vital statistician, 
the laboratory man must usually determine the 
sources and routes of disease, it is the Public 
Health Engineer to whom we must all turn 
wherever and whenever those sources or routes 
can be put out of action by physical construction 
or mechanical device, or when economic mal- 
administration of public utilities is the real basis 
of the trouble rather than a physical condition. 

The Public Health Engineer is not, however, 
as a rule, a man of a biological turn of mind. 
He generally takes vital statistics too seriously 
and, lacking medical knowledge, interprets vital 
statistics too mechanically. His own units of 
weight, volume, and measurement are fixed and 
definite. He has not learned to scan the unfamil- 
iar units of disease, each by itself ; nor is it likely 
that as a class he ever will. The spectacle of an 
engineer advising on a strictly medical problem 

83 



is only less sad, if less sad at all, than that of a 
medical man. advising on a strictly engineering 
problem. It is in co-operation, each perfect in 
his own field, but aiding the other with real un- 
derstanding of the other's problem, that well- 
balanced, sane advance is made. 

So far as the five great routes are concerned, — 
water, food, milk, flies, and contact, — the engi- 
neer has so far found his chief field in dealing 
with water supplies. Even sewage disposal, so 
far as it is a sanitary problem, has as yet been 
chiefly considered in so far as it might affect 
the purity of water. But in the future the engi- 
neer must also deal with milk supplies, their 
production, transportation, pasteurization, disin- 
fection ; with the great fly problem and its chief 
corollary, the safe disposal of human excreta, 
as well as its minor corollaries, garbage and ma- 
nure removal. Finally, perhaps chiefly, he must 
deal with the great sociological factors on which 
rests contact infection in public meeting-places, — 
the factory, the shop, the church, the theater, the 
school, even the tenement and the private home. 
Above all, the great engineer of the future is he 
who will see with trained analytical mind and 
act with trained administrative ability in organ- 
izing or re-organizing not one but a dozen of 
the many factors in the modern complex of 
society along lines which shall in themselves 
redistribute concentrated forces now too closely 
interwoven for mutual good. 

But there must be more public health in en- 
"I'ineering rather than more engineering in public 
health. This series of papers will have failed 
wholly in pointing out the real essential inside 
truth of public health progress if it leaves be- 
lief that infectious diseases can be abolished 

. 84 



t> 



through any physical or mechanical means. The 
great engineering operations of the day have an 
importance to mankind much greater in socio- 
logical and economic lines than in public health. 
But the public health end must not be neglected, 
even though we recognize that it can never be the 
great end of engineering, because no mere guard- 
ing of such routes of infection can abolish dis- 
ease, and, if it could, there are far more direct, 
drastic, and simple measures to be enforced in 
other directions than in the protection of public 
utilities. Great engineering works are not es- 
sential to the abolition of infectious diseases, 
but great engineering works should be so con- 
ducted as to secure what reduction in such dis- 
eases it may. The ultimate abolition of infectious 
diseases rests with the supervision of the infec- 
tious individual, and no mere adjustment of sur- 
roundings can so afifect his conduct as to compel 
that conduct along proper hnes. But the public 
health engineer through housing, organization, 
and the proper construction and supervision of 
public utilities can so design the lines of least re- 
sistance that the public, w4io generally follow 
these lines, will find them plain and smooth, but 
hedged about with iron walls of safety. 

SUMMARY 

It is a complete misnomer to designate as a 
sanitary engineer him who merely narrows his 
attention from the principles and practice of 
engineering in general to the appHcation of these 
principles for the purpose of constructing water 
supplies, sewage-disposal systems, rendering of 
garbage, etc. 

A man is not a sanitary engineer because he 
can lay down sewer pipe any more than a man is 



an artist because he can lay on paint. The Public 
Health Engineer in the true sense is he who has 
acquired so wide a view of modern life, of its 
mechanisms, and of the physical side of man's 
environments, that he can see and act through 
them for man's physical protection not merely 
from accident but also from disease. He does not 
just build sewers. When he builds them, he 
builds them as part of the great fabric of mod- 
ern life. His plans are not merely so many feet 
of pipe, at such a price per foot : they are adapta- 
tions and applications of great fundamental laws 
to the physical advancement of mankind. 



86 



Chapter VIII 
COMMUNITY DEFENSE 

THE PUBLIC-HEALTH LABORATORY 

The previous chapter discussed the relation of 
the PubHc Health engineer to the protection of 
man from disease, through the construction, 
operation, and direction of those public utilities 
already proved to be, at times, routes of infec- 
tion. 

Some day, when we have really determined the 
conditions which truly promote physical well- 
being, as distinguished from those which merely 
secure escape from disease, the Public Health 
engineer will find larger functions in a wider 
field, the supervision of the whole material sur- 
roundings of man. 

The present chapter attempts to set forth the 
relation of the Public Health laboratory man to 
the same two divisions, — to the promotion of 
high health, on the one hand, and to the preven- 
tion of disease, on the other. Like the Public 
Health engineer, the Public Health laboratory 
man can as yet contribute but little to the for- 
mer, and for the same reason, i. e., because so 
little is really known about it. Like the Public 
Health engineer, the Public Health laboratory 
man deals with the prevention of disease, and 
chiefly with the prevention of the infectious dis- 
eases. Again, like the engineer, the laboratory 

87 



man deals in part with routes of diseases, with 
those pubHc utiHties which at times form high- 
ways for the exchange of -infected, and unin- 
fected, bodily discharges. But, unlike the en- 
gineer, his work is not confined to routes. 

The Public Health laboratory man, like the 
epidemiologist, deals also with sources, i. e., 
with the infected person. In some ways he goes 
further than the epidemiologist, for he deals with 
the infected discharges themselves, rather than 
with the person who discharges them; and, not 
stopping even there, he deals with, in those dis- 
charges, the very principles of disease itself, — 
the individual little particles of living matter 
whose activities in the human system produce 
so much trouble for us all. 

This dealing intimately with the ultimate 
causes of disease is a fascinating, dangerous, pe- 
culiar life-work, an actual herding, handling, 
studying, of the very essences of the dreaded 
plagues of old. What would not the ancient 
philosophers and sages have given for one 
glimpse of a modern Public Health laboratory 
where matter-of-fact men handle, in their daily 
matter-of-fact routine, diphtheria plants, typhoid 
plants, tuberculosis plants, etc., quite as a student 
farmer handles potatoes or corn? 

Because the little plants, or animals, perhaps, 
that produce many of our common diseases are 
as yet unrecognized, for instance, scarlet fever, 
measles, and smallpox, to name only three, the 
Public Health laboratory man's chief daily duties 
lie with- typhoid, diphtheria, and tuberculosis. 
These furnish the bulk of his work. His chief 
services to mankind, in the temperate zone at 
reast, consist in the aid he gives in recognizing 
those persons who are infected with one of these 



three germs without showing conclusive, perhaps 
any, symptoms of their presence. True, he can 
and does perform like services in other diseases 
whose causes are recognized — such as anthrax, 
bubonic plague, cholera, glanders, leprosy, etc. ; 
but these are so rare as to form only a flavoring 
for his daily grist. In the venereal diseases, also, 
the biological causes are known and can be rec- 
ognized, but the laboratory man must await the 
development of the growing public demand for 
the handling of these diseases on a par with 
other infections, the taking up of these great 
subjects by legislative and executive authorities. 
Until that time comes the laboratory man can 
proclaim his own readiness and point to the 
road, but he can do little more. 

With the routes of infection, — water, flies, 
food, milk, and contact, — the laboratory man has 
much to do, but, again and for similar reasons, 
he deals with these routes, in the temperate zone, 
chiefly when typhoid, diphtheria, or tuberculosis 
are involved. His functions in all this work are 
chiefly analytic, i. e., to find the particular water, 
or milk, or food which may be dangerous ; some- 
times to detect, if he may, the presence in them 
of the deadly germ itself. 

Unfortunately, for reasons already offered in 
a different connection (see Chapter II), the 
germs of disease are very rarely found in water, 
food, milk, or flies. They live so short a life out- 
side of the human, or animal, bodies which form 
their natural growing-grounds that the labora- 
tory man seldom encounters them except in the 
body. The usual thing is, that long before a 
''sample" of water, etc., arrives at the laboratory, 
the disease germs it may once have held are 
dead or so outgrown by others that the best lab- 

89 



oratory methods must necessarily fail to find 
them. 

So little is this Understood that one of the 
almost daily happenings in every laboratory is 
the receipt of water, or milk, or food (flies, for- 
tunately, are not often sent, as yet) from lay- 
men, even from physicians, with the request that 
they be searched for typhoid or diphtheria germs. 

But consider ! Before a given water supply 
has attention called to it as a source of typhoid 
fever, typhoid fever cases usually must have de- 
veloped from it. But typhoid fever is a disease 
which does not develop even its very first symp- 
toms until, on an average, two weeks have 
elapsed after the germs first entered the body 
from the water supply. Usually, another week 
passes before the physician is called and perhaps 
another week, more often two or three, before 
the sample is sent ; therefore five weeks is perhaps 
the usual time which has slipped away since the 
typhoid germs were present in the water supply, 
before the laboratory man receives a sample from 
it ! Now, two weeks is probably the usual maxi- 
mum for typhoid germs .to live in water, even 
if the water be stagnant and in a dark place. 
When it is heaving, changing, exposed to the sun 
and wind and current, or flowing fast, as in a 
river, the life of disease germs in it is even short- 
er, and the chances of their dispersion and dis- 
appearance by the mere physical losing of them- 
selves are almost infinite. To apply laboratory 
methods to finding typhoid germs in the ordi- 
nary sample of water taken from the suspected 
supply five weeks after the cases were infected, 
would be like shooting at the place where a flock 
of ducks had been five weeks before. ''Hunting 
for a needle in a haystack'' is discouraging 

90 



enough in itself, but suppose you knew the needle 
had been carefully removed before you began 
your hunt ! 

The laboratory man who exammes water does 
so, not in the hope of finding typhoid germs, — 
he does not even try to look for them, as a rule, — 
but to find certain other signs of excretory pol- 
lution. Curiously enough, these signs are often 
of more real value to Public Health than would 
be the finding of the typhoid germs themselves, 
were that practicable ; but to explain how this is 
would be out of place here. The point is this : 
The laboratory tests of the supposed routes of 
infection in any given case are made by methods 
and for ends wholly dififerent from those which 
the public fondly imagines. The results obtained 
are often far more valuable than the public real- 
izes or expects. At the same time, the definite- 
ness of these results, because of the facts al- 
ready outlined, are far inferior to those obtained 
in the laboratory examination of infected per- 
sons — in brief, the information from laboratory 
sources concerning ''samples'' usually requires 
elucidation and explanation in the light of all 
sorts of other information, sociological, meteoro- 
logical, topographical, geological, etc. Consider- 
ed thus, the laboratory work is nearly invaluable, 
but, taken by itself, almost as nearly worthless. 

The happy ignorance displayed by those who 
think that an analysis of water, or milk, or food, 
even the most thorough, can in itself and by it- 
self give useful sanitary information is equalled 
only by the joyful confidence of the southern 
darkev in a rabbit's foot."^ 



♦The British ::Medical Association at its annual meet- 
ing, held this year, passed the following- resolution: 
"That this con-joint meeting- of the sections of State 
Medicine and Bacteriology unanimously desires 
strongly to urge that no opinion as to the quality of 

91 



The true position of the laboratory in the co- 
ordination of pubHc health workers which will 
rule in future organization, has been achieved 
but seldom. 

The Public Health laboratory man of today 
has ceased to be the leader in public health en- 
deavor which he once was, partly because he has 
been swamped with routine work in the lines 
he has himself developed, but chiefly because he 
is a laboratory man and because the very na- 
ture of his work has kept him indoors, out of 
and apart from the stirring fields of human life 
in being. Perfect enough in his own technic, 
he has perforce lost touch with all but his own 
work, and other lines of public health more 
closely involved with the outer world, have pass- 
ed ahead of his. 

The laboratory man must get out into the ac- 
tual daily lives of the people and communities 
he serves. He must know outside conditions as 
well as those in the laboratory. He must work 
more closely with the engineer and the epidemio- 
logist. He has his own place which they can fill 
no more than he can fill theirs, but he must un- 
derstand their work, and they his, much better 
than at present. 

Moreover, the engineer and the epidemiologist 
suffer from the present disassociation of the lab- 
oratory quite as much as does the laboratory man 
himself. Field work moves lamely, oftentimes, 
from lack of laboratory knowledge, just as lab- 
oratory work is oftentimes inert from lack of 
field knowledge. During the last few years the 
frequent transfer of laboratory men into the field 

a water for dietetic purposes should be arrived at on 
bacteriolog-ical evidence without a local and topo- 
g-raphical inspection of the sources of the supply made 
by a competent observer." 

92 



work of epidemiology and engineering has 
evolved a set of men who recognize this fully. 
But it is not by transferring laboratory men to 
other fields that the laboratory can be developed. 
It is by putting the laboratory itself into the field 
— and only so — that this can be accomplished. 

In field work, and in research, so much neg- 
lected of late, the laboratory man will find his 
future, and he will not deal solely, as at present, 
with infectious diseases. True, the venereal dis- 
eases must be added to the present list of those 
for which routine laboratory facilities are pro- 
vided. But some non-infectious diseases may be- 
come preventable diseases, if their causes are dis- 
covered, and the Public Health laboratory of the 
future, acting in conjunction with the physiolo- 
gist and the pathologist, may find therein useful- 
nesses now undreamed of. Finally, as we slowly 
learn the true personal hygiene of food, cloth- 
ing, sleep, exercise, etc., the Public Health labor- 
atory will take its share in the greatest but least 
developed of all Public Health procedures, name- 
ly, the physical regeneration of the race. 

SUMMARY 

The Public Health laboratory finds its chief 
functions today in the detection of infectious per- 
sons (sources) and in the identification of infect- 
ed things (routes) as a means to the end of abol- 
ishing those sources and blocking those routes. 
The average public health laboratory has been 
swamped with routine, cribbed, cabined, and con- 
fined until useful research has almost died out 
and real knowledge of outside conditions has 
been lost. The engineer and the epidemiologist 
have progressed fast and far by active contact 
with the needs of the outside world, and the lab- 
oratory can attain its proper future only by like 
development. 

93 



Chapter IX 
COMMUNITY DEFENSE 

THE PUBLIC HEALTH STATISTICIAN 

In the development of the new public health 
principles, the laboratory came first. It dealt 
with the causes of disease at first hand, as well 
as with their sources and their routes of trans- 
mission. On laboratory findings all modern pub- 
lic health is based, although in practice the lab- 
oratory is necessarily limited, for daily service, 
to those diseases the causes of which are known. 

But in its earlier work, the laboratory, inher- 
iting somewhat the environmental teachings of 
the older school, paid more attention to routes 
than it did to sources^ especially to the routes 
constituted by (a) water and (b) general sur- 
roundings. This focused attention on (a) san- 
itary engineering and (b) disinfection. It was 
in the earlier laboratory period that the sanitary 
engineer and the disinfector developed highly. It 
is true that the engineer deals almost solely as 
yet with but one route, water ; and that therefore 
his efforts necessarily relate almost solely to the 
intestinal infections, mainly to typhoid fever. 
Nevertheless, so valuable were his services in 
reducing this disease, that engineering work was 
hailed at one time as the solution of all public 
health questions. Now the epidemiologist leads 
the van, because he deals not with some routes, 

94 



of some infectious diseases, but with all sources 
of all infectious diseases. 

STATISTICS AS THEY WILL BE 

But, through the work of the laboratory man, 
the engineer and the epidemiologist has for long 
been heard a still, small voice, offering a frame- 
work to bind them all together — to give coher- 
ence, correlation, and proportion — to outline the 
future, as well as to record the past, and, above 
all, to direct the present. This was the voice of 
the vital statistician. Much abused, laughed at, 
neglected, he is, or will be, guide, map-maker, 
intelligence-department, all in one; he is, or will 
be, like the cost-of-production scientific manager 
of modern business, ''the most indispensable man 
on the staff." 

True, his professional ancestors were helpless 
old gentlemen, raising their feeble voices in very 
feeble chants. A dry-as-dust historian of the 
wars of ancient Greece could lend more aid to a 
modern football team than the old-time statisti- 
cian furnished to public health endeavors. Even 
now the new vital statistician is scarcely yet full- 
born. Hardly a health department now in ex- 
istence collects in full or uses to full advantage 
one-tenth the information that it really needs. 
(A notable exception should be recorded here, the 
Richmond (Va.) Health Department under E. 
C. Levy.) The laboratory man has made some 
good statistics in his own field; so has the sani- 
tary engineer — sometimes, alas, not wisely, but 
too well ; the epidemiologist, also, from sheer 
necessity : but the new vital statistician has only 
begun to move. When he does move, fully 
equipped, alert, he will systematize, organize, and 
use the rich data so far largely wasted, this very 



life-blood of public health endeavor, accurate, 
complete information concerning the way human- 
ity reacts to human ills. Internal public health 
organization has been like the old-time factory, 
full of good workmen, but each working only 
his own line, with no one person knowing much 
about the business as a whole. At the end of the 
year the business, drifting along, perhaps showed 
a doubtful profit, perhaps a loss, but so long as 
bills and wages were somehow paid, who cared? 
Public health requires exactly the kind of man 
who has changed the face of business in the last 
fifteen years, a man who understands all parts of 
it, but does none himself ; a man who knows costs 
in each department in proportion to production, 
and where to cut cost, increase production, save 
time, unnecessary work, and waste in general ; 
alas, in health departments, a man to stop the one- 
half, now done uselessly in wholly wrong direc- 
tions and to force development of the other half, 
now much neglected or left undone completely. 
It is the vital statistician who must do this : 
collect the facts and set them forth inexorably, 
with mathematical precision. When it is done, 
our health departments will no longer use up 
$30,000 for garbage, with the probability that not 
a single life will be saved thereby, while spend- 
ing $12,000 on all other health department ef- 
forts combined. Nor will a health department 
spend for terminal disinfection one-tenth its an- 
nual appropriation, to save no lives at all,"^ while 
using but one-fiftieth its appropriation for tuber- 
culosis, which kills five times as many people as 
all the diseases usually ''disinfected" put to- 
gether. 



*In tuberculosis, where terminal disinfection would be valuable 
it is not often done. 

96 



It will be said : "You are confusing vital 
statistics with health department finance ; vital 
statistics deal with deaths, not money/' Ex- 
actly — and that is just exactly what is wrong 
with them. Vital statistics are, in short, not 
vital; they deal with Death, not Life, with the 
''finished product" only of our slack, slipshod 
methods. They ought to deal, not with the dead, 
but who they were, and why and how they died, 
and why they were not saved. Suppose the fac- 
tory manager knew at the end of the year mere- 
ly his total product ! Suppose that even this 
piece of information related, not to the way busi- 
ness went last year, but to the way it went five 
years before. ''Historical records, and mighty 
poor at that," a modern public health man said 
in bitter scorn of the statistics of a neighboring 
state. The modern scientific manager must 
know not just the total product, though he must 
know that, and to the minute, not to five years 
before ; he must know also all about the product, 
the kind, the quality, the cost, and why it is not 
better for the price. The modern vital statis- 
tician must know not only deaths, but why the 
health department is not stopping them ; what 
its funds are ; how they are spent or wasted ; 
what w^ork is being done ; how much of value 
each division does ; and all to the one end of 
saving life, not to the end of stopping nuisances, 
removing garbage, or cleaning streets — all admir- 
able ends no doubt, but not life-saving ends. 

But, it will be said, "Very well, but you are 
wrong in stating that Vital Statistics deal with 
Deaths. They deal w4th more than Deaths — 
they deal with Births and ^Marriages and con- 

97 



tagious diseases also." Yes, nominally; but to 
what useful end for public health ?'*' 

''Birth records quite often afifect inheritance 
of estates in later years/' True, and very useful 
to the inheritor they are when the time comes, 
but what has that got to do with saving life now ? 
Marriage records also are invaluable in their own 
way, but they do not reduce tuberculosis one- 
tenth of a tenth per cent. Contagious disease 
reports, then? Surely they are important? Yes, 
but not as they are now collected. Misleading 
information is sometimes worse than none at all. 

STATISTICS AS THEY ARE 

The best way to show what public health vital 
statistics as they are today mean, or do not mean, 
is to give the story, true to life, as anyone who 
knows will quickly see, of the very basis of such 
statistics, the actual facts as they occur amongst 
the people. 

Mrs. Anybody says to Mr. Ditto : 'T am 
afraid Tommy has scarlet fever ; I think he must 
have caught it when he was in the city.'' ''Call 
Dr. A." "Yes, but they say he will report it, 
if it is scarlet fever. I'm nearly wild now with 
work. When the children are at school all day 
I manage somehow ; with you and the children 
quarantined at home for a month I should go 
insane. I'll call Dr. B. ; they sav he never re- 
ports anything. I'll tell the neighbors it is scar- 
let rash. That's not a lie. It's a rash, and it 
certainly is scarlet. I'll let the children go to 
school, but I'll keep every one away from Tom- 
my. I'd hate to think any other child g-ot it 
from our children, but I guess that will be all 

♦Birth records, if they led to immediate investiga- 
tion to see that the child was cared for properly, would 
be true public health data. 

98 



right. Tommy is not very sick yet. Don't go 
telling anyone he is sick. I'll tell the children 
not to, either. We don't want to have the milk- 
man or the grocer afraid to call." 

So Mrs. Anybody plans, and so it is carried 
out. But her heart is bigger than her head, and 
her plans go strangely awry. 

She puts Tommy in a room by himself and 
runs over to a neighbor's for an tgg or a cup 
of flour. When she comes back the other child- 
ren are lined up in Tommy's room, solemnly in- 
specting the rash he proudly demonstrates to 
them. Next morning Tommy is "real sick," 
and after breakfast the mother puts up the other 
children's school lunches alternately with running 
in to Tommy's room to give him water or to hold 
the basin while he vomits or just to kiss and 
soothe him. 

Poor, loving, hard-working mother ! She 
has done the same through all the ages, taking 
infected discharges from the sick child, on her 
hands to put in the other children's food ! 
No, she won't kiss them goodbye ; she has been 
kissing Tommy; that is, she won't kiss any but 
the smallest one, who looks nearest to crying. 
That one's mouth she wipes with her apron 
before she kisses it — she does not zvipe her own! 
Not that wiping either matters, for Tommy's 
mouth discharges are already in the lunch the 
little one marches out with, under its arm. 

About 10 A. M., the empty house and the wail- 
ing child get on the mother's nerves. So she calls 
in a neighbor. ''Tommy's sick. I want to go 
to the store to telephone the doctor. It's only 
scarlet rash. I won't be gone more than a min- 
ute, but I'm afraid he'll get out of bed or some- 
thing. Will you keep an eye on him?" 

99 



The neighbor comes in, the baby on her arm, 
for is it not scarlet rash? But prudence strikes 
her suddenly, and she sets the baby on the floor 
before she peeks in at Tommy. ''Hullo !" "Hul- 
lo, Mrs. Neighbor!" a feeble little voice replies. 
She steps in further, leaving: the door open to 
keep an eye on baby. ''Well, Tommy, how do 
you feel?'' "Not very well," and he begins to 
vomit. She snatches a basin, holds his head, and 
in a moment surrenders him to his mother, and 
then takes her baby hurriedly home. A speck of 
vomit-spray has hit her hand. She did not no- 
tice it. The baby's fingers rest on it a moment, 
before it is dry; a minute later the baby sucks 
that finger. At home she sets the baby down 
and, conscience-smitten, changes her dress {she 
does not wash her hands!) and thereafter feels 
all right again because she thinks that nozv she 
can't give it to anyone, even if it is scarlet fever ; 
besides, the doctor said it was scarlet rash. 

Meantime, Mr. Anybody, summoned by his 
wife, hurries home in terror, finds Tommy still 
quite alive, growls, fusses, brings in some wood, 
pumps a little water, and then steps into Tom- 
my's room, "just inside the door for a minute," 
before going down-town again. Tommy, with 
feverish, flushed face and heavy eyes under his 
tousled hair, calls feebly, "My daddy, my dad- 
dy" ; and, of course, Mr. Anybody steps to his 
bedside to pat his head and kiss him, before 
hurrying back to business. 

That night Tommy is worse; sorrow is on the 
family in earnest. Next morning Tommy is 
much better; the prayers and tears of the night 
before are forgotten; the mother, weary but joy- 
ful, lets the other children in to see him; "just 
for a minute now, but, anyway, he is so much 

100 



better"; and they all race out to school, shoutin<T^ 
and laughing. 

About five days later, Susan, the youngest, is 
not feeling- \ery well towards evenin^-, vomits 
during- the night, is delirious next morning, with 
sore throat, swollen neck, and rash ; and Dr. B. 
comes again. Serious measures are taken. The 
other children, in tears, are spirited away to a 
cousin's house to stay lest they should get it, and 
because the mother can't stand the strain of 
nursing the sick and caring for the well also. 

Tommy has had it mildly, and by this time is 
up and about, wandering disconsolately through 
the empty house. To all inquirers the mother 
bravely maintains that Susan has only the scarlet 
rash and tells them Tommy will go back to 
school in a day or two. 'T just sent the other 
children away because they were so noisy,'' she 
explains guiltily; wishing very earnestly that it 
was really so. 

Next day Susan is better. (I am writing this 
— and therefore I make it thus. In real life, 
poor little Susan often dies, instead.) Every- 
one is cheerful again. Tommy is sent, very un- 
obtrusively, to school because ''he mopes at 
home, without a soul to play with.'' He is be- 
ginning to peel, and, in a day or two, is in much 
demand amongst his schoolmates, presenting 
them with souvenirs of flakes of skin they treas- 
ure as curiosities. Not that these scales do 
harm, despite the old beliefs. It is not the peel- 
ing, which everybody sees, that does the mischief, 
but the unnoticed slightly red sore throat that 
Tommy carries with him, and from which he 
infects his hands (and everyone he touches) and 
shoots out infection in his mouth-spray as he 

101 



chants his lesson, or whispers across the aisle, 
or sings in class. 

And so the old, old story works itself out in- 
exorably. One of the other children, staying at 
the cousin's, develops a slight sore throat. Were 
there an epidemiologist at hand, posted on the 
history of the child, to scan the enlarged papil- 
lae of the tongue, note the large glands, and see 
the filmy membrane on the tonsils, the case 
would be recognized as scarlet fever, sine erup- 
tione, i.e., without a rash. But as it is ''it's 
only a sore throat." No physician sees her, be- 
cause the cousin argues thus: ''If it were my 
child, Fd have in Dr. A., but Mrs. Anybody 
wouldn't thank me for running up another bill 
here, unless the child is really ill; she's having 
Dr. B. now, for Susan, twice a day. I'll wait a 
day or two, anyway." 

The sore throat mends, and the cousin feels 
she made a good judgment. But meantime the 
sore-throat girl has been sleeping with the cous- 
in's little girl, and she develops it, too, but it also 
passes off. Then a week later, the cousin's little 
girl's school-chum, in a different school from 
Tommy's, has scarlet fever proper. Dr. A. at- 
tends, and reports it. The Health Department 
puts a placard up; the children are kept out of 
school ; the father is kept at home ; the whole 
population turns its eyes to that family and won- 
ders where they got it. The village wiseacres, 
over the village bar, remind each other of the 
slough behind the house, or that the garbage from 
the family was never removed all summer. They 
say the well is shallow, "nothing but surface 
water," or the house is damp, or too much shut- 
in by trees, or any other fatuous foolishness that 
enters their empty heads. The mayor gives out 

102 



a statement to ''allay popular excitement." He 
brands as malicious all statements that scarlet 
fever is rampant. There is but one ''sporadic 
case," originating no one knows how. It is care- 
fully quarantined, and "the Health Department 
believes the outbreak is well in hand and prac- 
tically stamped out." The Women's Club de- 
mands the fumigation of the schools ; and the 
epidemiologist, if he were only present, would 
gaze reflectively at Tommy's slight red throat, 
and gnash his teeth, and swear.* Poor Dr. A., 
who only did his duty, is blamed for all the 
trouble; and Dr. B. keeps mum. When, pres- 
ently, Dr. C. is called to one of Tommy's school- 
mates, he hesitates. He has not seen much scar- 
let fever, and he thinks, "perhaps it is scarlet rash 
— whatever that may be." He attends the child 
two or three days, and then he begins to ponder 
whether or not he had not best put the responsi- 
bility on the Board of Health ; so at last he calls 
up Dr. D., the Health Officer. But Dr. D. has 
troubles of his own. "Do you say it is scarlet 
fever?" "Well, I don't know. I want you to 
go and see." The H. O. is perplexed. He does 
not want the reputation of finding a second case, 
after the Mayor has stated that there is only 
one; so he tells Dr. C. : "H you report it, I'll 
placard the house, but I don't want you to report 
it, if you are not sure." At this Dr. C. waits a 
day or two more, but finally reports it. Mean- 
time a week of association of the other children 
with the sick one has elapsed, because Dr. C. did 
not quite know the finer points in recognizing 
mild scarlet fever early. 

♦Editor's IVote. — We regret the epidemiologist should 
do this, but we propose to give the facts, no matter 
whom it hits. Besides, we do not blame him much un- 
der the circumstances. 

103 



By this time, between the unconscious activ- 
ities of Tommy and Susan, who are back at 
school, well oiled by Dr. B/s advice, to keep the 
scales from showing, and of Susan's sister and 
the cousin's little girl (none of them recognized 
officially as scarlet fever), some twenty or thirty 
children in the two schools have been infected. 
Some of the pupils have had scarlet fever before 
and so escape this time. In others the disease is 
mild and passes unnoticed. In others ''scarlet 
rash'' develops. But several develop frank scarlet 
fever, not to be denied even by Dr. B., who, to 
give him credit, has begun ''to get a little 
scared," and so reports one or two well-marked 
cases to relieve his conscience. Two or three 
deaths occur, and then the schools are closed, 
but not the Sunday-schools, or churches, or pri- 
vate sociables, or moving pictures, and so it 
drifts. 

Now, see how all this affects vital statistics. 
The Health Department, in its annual statement, 
gives as the first case that school chum of the 
cousin's little girl. But we know that there were 
four cases before that — Tommy and Susan, and 
Susan's sister, and the cousin's little girl — but 
these do not go down upon the books at all. 
The Health Department adds thirteen more 
cases ; that is, all those cases attended by Dr. A., 
faithful, conscientious man ; about half of Dr. 
B's cases, those he had after he "got scared" ; 
and some of Dr. C's, but only those he was abso- 
lutely certain of, not knowing scarlet fever very 
well. Dr. D. had no cases, because being health 
officer, the mothers felt that he would have to re- 
port them, and so did not call him. 

The fact is, that any epidemiologist would find 

104 



that there were forty cases, but the books show 
fourteen. 

Then consider the deaths. Two are reported 
properly as due to scarlet fever. But one of Dr. 
B's, really scarlet fever, not quarantined while ill, 
is reported "acute Bright's disease/' because the 
doctor dare not say it died of scarlet fever after 
treating it a month without reporting it. It is 
quite true the child had Bright's disease, but it 
had Bright's disease because it had scarlet fever. 
Another dies of meningitis, due to middle-ear 
infection, the result of scarlet fever, but being 
meningitis, this death also goes in a different 
column. The more or less spoiled ears and the 
more or less spoiled kidneys of twenty other 
children who recovered never are recorded on 
the books at all. 

Hence, fourteen cases where there should be 
forty; and two deaths, where there were really 
four, are recorded officially as scarlet fever. 

This instance exemplifies practically the whole 
situation ; mild, unrecognized, and concealed 
cases ; cases to which physicians are not called at 
all ; mistaken diagnoses ; a superficial report cov- 
ering a few of the severer cases only ; death re- 
ports correct so far as they go, but not showing 
the relation of the death to the preceding dis- 
ease. This occurs, not occasionally in a few 
communities, with scarlet fever only, but, almost 
every time, in almost every community, with al- 
most every one of the infectious diseases. 

The returns from Anybody ville are small in 
number, it is true; but multiply these by all the 
similar communities which make similar returns. 
Anybodyville reports two deaths and fourteen 
cases from scarlet fever, where there were four 
deaths and forty cases. This is ''only" two 

105 



deaths and twenty-six cases wrong. But if one 
thousand communities report similarly, our sta- 
tistics are wrong two thousand deaths and 
twenty-six thousand cases. 

Moreover, see how the percentages are twisted 
and tangled. Two deaths from fourteen cases 
is about 14 per cent. Two deaths from forty 
cases is 5 per cent. Four deaths from fourteen 
cases is 28 per cent. Four deaths from forty 
cases is 10 per cent. When we remember that 
the number of cases of scarlet fever, and of 
other diseases, is often calculated from the 
deaths by the percentage which the deaths usu- 
ally are of the cases, we find that we can cal- 
culate the cases from one hundred deaths of scar- 
let fever (on the above returns) as seven hun- 
dred, two thousand, three hundred and fifty, or 
one thousand — how very valuable ! 

SUMMARY 

The vital statistician of the future will be the 
scientific manager of a business department, for, 
through the epidemiologist working in the field, 
he will know where the diseases are^ not w^here 
they were, and he will know which disease de- 
mands the most attention. He will know also 
what resources, in men and money, the health 
department has, to fight its battles with. The 
correlation of these two factors has seldom been 
achieved, rarely even attempted, in public health 
circles, although in life insurance it has long 
been known that their inter-relations were the 
absolute sine qua non of success. Any business 
man's first step in reorganizing public health for 
actual service would necessarily be (a) to de- 
termine what requires to be done; (b) to de- 
termine what there is to do it with. The max- 

106 



imum required returns from the minimum nec- 
essary expenditure should be the only motto. 
To secure this information, no one but a statis- 
tician knowing statistics, but knowing men and 
things as well as figures, can succeed. To con- 
fine his work to deaths, even to cases, from pre- 
ventable diseases, is to study output only, with 
no regard to income. To study income, as is so 
widely done, without regard to whether that in- 
come is spent to achieve lessening of disease and 
death or merely for nuisances or smoke inspec- 
tion, is simple madness. 



107 



Chapter X 
COMMUNITY DEFENSE APPLIED 

TUBERCULOSIS IN GENERAL 

Previous chapters have outhned the general 
principles which govern modern pubhc health 
efforts. The present chapter will show the spe- 
cific applications of these principles to one specific 
infectious disease, namely, tuberculosis. This 
disease is selected because the same principles 
that apply to all other infectious diseases apply to 
it and because it is the most important of all the 
diseases now recognized as really preventable, 
with the exception of the venereal diseases. 

Tuberculosis, in all forms, is due to the growth, 
somewhere in the body, of a certain germ, ex- 
actly as diphtheria and typhoid are due to the 
growth, in the body, of certain germs. There 
are many very definite individual differences, in 
the size, shape, manner of growth, etc., of the 
three different germs of these three different dis- 
eases, and these differences make it perfectly pos- 
sible to distinguish each germ from the others, 
just as any farmer can distinguish oats, corn, 
and potatoes from each other. 

But just as there are different varieties of 
potatoes, so there are at least two varieties of 
tuberculosis germs which affect human beings. 
One variety is what is known as the human tu- 

108 



berculosis g-erm proper. The other is found 
chiefly in cattle and is therefore called the cattle 
tuberculosis germ (the bovine tuberculosis 
germ), and this name is given to this variety 
even when it is found in the human, as it some- 
times is. 

HUMAN TUBERCULOSIS 

A most important difference that the germs of 
human tuberculosis, of diphtheria, and of typhoid 
fever show amongst themselves is not a differ- 
ence in size, shape, etc., but in the parts of the 
body each selects. Thus the diphtheria germ 
flourishes chiefly in the nose and throat ; the 
typhoid germ flourishes chiefly in the intestine 
and perhaps the blood; while the human tuber- 
culosis germ will flourish almost anywhere in 
the body, glands, bones, joints, intestine, kidney, 
brain, lungs. This selection is no mere accident, 
although we do not know how it comes about. 
All three germs enter the body chiefly by the 
mouth, conveyed thereto chiefly by the hands, 
but also more or less through food and milk, and, 
in the case of typhoid fever, through water and 
flies. On entering the mouth, all three germs, 
which are of course far too small to taste or feel, 
are swallowed in the food, milk, etc., in which 
they happen to be present, or merely in the saliva, 
if, as is most usual, they reach the mouth di- 
rectly or indirectly from the fingers. Once swal- 
lowed, all three pass into the stomach, where 
many are killed by the acid there present, the 
survivors, if any, passing on into the intestine. 
On this journey from mouth to intestine, some 
are left, of course, by the wayside, stranded on 
the tonsils, throat, gullet, etc. Here at once is 
shown their respective peculiarities. Of all the 
diphtheria germs that are thus swallowed, prac- 

109 



tically only those that are stranded in the throat, 
will flourish; those diphtheria germs which pass 
on into the stomach or intestine are destroyed 
or pass out harmlessly. On the other hand, ty- 
phoid germs, if stranded on the throat, do not 
flourish there, nor do those which reach the 
stomach flourish in that organ. It is only those 
typhoid germs which survive the journey until 
the intestine is entered that can succeed in pro- 
ducing typhoid fever. The human tuberculosis 
germ has a still longer road to go. Not only 
must it pass mouth, stomach, and intestine; 
also it must be absorbed from the intestine into 
the blood, as the food is ; but it does not grow in 
the blood. The blood is only a river, by which 
it can be carried to a favorable developing 
ground. We do not know at all why human 
tuberculosis germs entering the blood thus, 
should finally settle and grow in a joint in one 
person, in a lung in another, in a kidney or a 
gland or a bone in another. However, this is the 
way in which these dififerent forms of human 
tuberculosis develop. The old idea that human 
tuberculosis of the lung (consumption) is con- 
tracted chiefly by breathing the germs directly 
into the lungs has been definitely upset. The 
lungs are infected from the blood-stream chiefly, 
just as are the other internal organs, bones, and 
joints. 

Another and, from the public health stand- 
point, an even more important difference exists. 
Diphtheria germs developing in the throat, and 
typhoid fever germs developing in the intestine, 
can readily escape from the body : in the case of 
diphtheria, through the mouth and nose dis- 
charges ; in the case of typhoid fever through 
the bowel, and sometimes the bladder, discharges. 

110 



It is the escape by these channels of these germs 
from tlie body which makes these diseases 
'"catching-" or ''infectious'' or ''communicable/' 
for if they could not escape from the body they 
could not reach other persons and therefore 
could not be "catching." But in human tuber- 
culosis, most of the places where it develops, — 
bones, glands, joints, etc., — are not connected 
with any opening of the body by which the germs 
may leave the body. These forms of tuberculosis 
have no great highway to the outside lying at 
their doors to carry the germs out to other per- 
sons. Practically only in human tuberculosis of 
the lungs are such highways provided for the 
human tuberculosis germs, although sometimes in 
bladder, kidney, and intestinal tuberculosis. But 
in the latter forms, the germs do not, as a rule, 
pass out by the highways provided for them in 
such condition or such numbers as to be of serious 
importance in propagating the disease. In human 
lung tuberculosis, on the other hand, the wand- 
pipe, throat, and mouth form a highway, along 
which the germs may escape from the affected 
lung in such enormous numbers that twenty-four 
billion per day have been detected in the dis- 
charges (sputum) from the lung of a single ad- 
vanced case, although the average number from 
the average case is usually "only" four or five 
billion daily. 

Thus it comes about that human tuberculosis 
of the lungs is the only common form of human 
tuberculosis which is much to be feared as in- 
fectious. Practically all the other forms of hu- 
man tuberculosis are derived from the sputum 
of cases of human lung tuberculosis, carried 
chiefly by mouth-spray and on the hands, and if 
cases of human lung tuberculosis did not act to 

111 



spread infection to other persons, all forms of 
human tuberculosis would quickly disappear. 

Moreover, even human lung tuberculosis is not 
very infectious in the early stages, i. e., when the 
germs are growing in the lung tissue, but have 
not yet reached the air-passages, because, until 
then, the germs cannot escape into the windpipe 
and so by the throat to the mouth. When in the 
later stages the germs reach the air-passages the 
way for the escape of the germs to the outside 
and so to other mouths is ''open." Persons in 
this stage of tuberculosis are called ''open" cases, 
and it is therefore only the "open" cases that are 
seriously to be feared as infectious. 

THE ABOLITION OF CATTLE TUBERCULOSIS OF THE 
HUMAN 

Although the cattle tuberculosis germ differs 
from the human tuberculosis germ somewhat in 
size, shape, etc., the most important public health 
difference is this : the cattle tuberculosis germ 
seldom produces lung tuberculosis in the human. 
It produces bone, gland, joint, etc., tuberculosis, 
but lung tuberculosis hardly ever. Consider how 
important this fact is. It means that cattle tu- 
berculosis existing in a human can very seldom 
be conveyed from that human to another human. 
In other words, cattle tuberculosis may be trans- 
mitted from cattle to man, but practically is not 
further transmitted from man to man. To pre- 
vent cattle tuberculosis in the human, we do not 
need to take into account existing cases of cattle 
tuberculosis in the human, but only existing cases 
of cattle tuberculosis in cattle. If we free our 
cattle of cattle tuberculosis, we shall free our 
humans of cattle tuberculosis also ; and this is the 
only practical way that cattle tuberculosis in the 

112 



human can be abolished unless and until the hu- 
man race abandons the use of cow's milk raw. 

THE ABOLITION OF HUMAN TUBERCULOSIS 

How can we abolish human tuberculosis? Ex- 
actly as we can, and some day shall, abolish any 
and all other infectious diseases, by killing off 
the germ that causes it, exactly as we have al- 
most abolished the race of buffalo by killing off 
the existing buffalo. We know well enough that 
when the last buffalo is dead, no man, however 
wise, no government, however powerful, could 
over produce another buffalo. So, once the ex- 
isting diphtheria or scarlet fever or tuberculosis 
germs are all dead, there is no way under heaven 
by which these particular germs could be pro- 
duced again. Those which exist now are not 
"evolved from dirt" any more than are buffalo or 
roses. Those which are living today are dimply 
the descendants of those which existed yester- 
day and so on, just as in the case of buffalo or 
roses, back to the dawn of history. Once anv 
race of plant or animal is wiped out, it can never 
be redeveloped; and the tuberculosis germ, just 
as well as the germs of diphtheria or typhoid 
fever, can be abolished exactly as the mega- 
therium or dinosaur has been abolished, i. e., by 
killing off the existing individuals. 

''But consider the enormous numbers and the 
tiny size of germs and that they are present 
everywhere, — in air, water, food, milk, dust; in 
and on everything we touch or taste or handle. 
It is quite impossible to kill them all.'' 

True, germs are everywhere but not disease 
germs. We know some fifteen hundred or more 
species of germs and hardly fifty of these pro- 
duce disease, while only two, already mentioned, 
produce tuberculosis in the human. That these 

113 



germs are very small and cannot be slaughtered 
individually like buffalo, is true, but it is also true 
that their very minuteness means that billions can 
be slaughtered at a time, if they are only kept 
together. As to tuberculosis germs being every- 
where, all over, outdoors and indoors — this is 
not true. No more important fact in public 
health has ever been formulated than this, due 
to that keen leader in public health, Chapin of 
Providence : The germs that produce disease 
are not ubiquitous, not in dust everywhere, water 
everywhere, milk everywhere. They are chiefly, 
almost wholly, in the bodies of a relatively few 
people, or animals ; and when they escape from 
those bodies, where alone they find the peculiar 
food, high temperature, abundant moisture, and 
darkness which they need, they promptly die or 
become harmless. Even in water, milk, food, 
etc., into which they may be introduced from in- 
fected persons, their lives are short, and they 
must quickly reach a new living victim, or die. 

To abolish any one race of disease germs is 
far easier than to destroy some much larger 
things. Thus to abolish flies means not only kill- 
ing all flies, indoors in all houses everywhere, in 
all stables everywhere, in and around all dwell- 
ings everywhere, but also throughout all fields 
and forests, mountains and valleys everywhere, 
because flies are hardy outdoor beings as well as 
indoor beings. They can breed and flourish al- 
most anywhere, where any kind of food, even in 
vanishing quantity, is to be had. Moreover, they 
can move of their own volition with promptness 
and despatch, have quick eyes and quicker wings 
to escape designing enemies, and in a thousand 
ways can take care of themselves. 

Disease germs, in contrast with the fly, are 

114 



very tiny and helpless particles of protoplasm, 
having no eyes to see an enemy, no nose to smell 
him, no means of running away from him. They 
cannot flourish on almost any food, but need the 
living tissues of the human body ; they cannot grow 
at alrriost any temperature, but must have the 
heat of the human body. In brief, they are not 
merely indoor plants : they are incubator plants 
and cannot grow, thrive, or reproduce themselves 
in nature, except in the incubators, our bodies, 
or, in a few cases, animal bodies, provide them. 
Hence if we were able to take a visual census of 
all the living tuberculosis or scarlet fever or diph- 
theria germs in the world we should see them, 
not in the dust everywhere, the water every- 
where, the food everywhere, etc., but in a very 
few places only, and those places would be, in 
almost all cases, the bodies of humans (or ani- 
mals). 

Indeed, we can foretell just about what the 
census of tuberculosis germs in any district of 
the temperate zone, would show. It would show 
about one person in every seven hundred of 
the population carrying a large number of active, 
living, growing germs in the lungs, — germs that 
were escaping to the outside and reaching other 
persons' mouths. It would show also a number 
of other persons in whom the germs were pres- 
ent in joints, bones, glands, etc., but not escaping 
to others ; and it would show a number of per- 
sons affected in the lungs, and, later, likely to 
develop to the point where the germs could 
escape, but practically harmless to others so far. 
Beyond this, hunt high, hunt low, search gar- 
bage barrels, manure heaps, dead animals, dusty 
streets, sewage, water, foods, milk, etc., and 
human tuberculosis germs, alive, growing, capa- 

115 



ble of producing the disease, would not be found 
True, in the immediate neighborhood of the* 
''open" cases the sputum they throw out, their 
mouth-spray, and their hands would show the 
germs, and things they spit into, mouth-spray 
into, or touch, would show for a short time a 
few; but these would be dying or already dead, 
holding out danger to. other persons only during 
the short time which elapses between leaving 
their happy homes in the human lung and death 
outside from drying and starvation. This ap- 
plies, not to tuberculosis germs alone, but prac- 
tically to all the germs of the ordinary infectious 
diseases, anthrax and tetanus forming two chief 
exceptions, both rare diseases here. 

No person energetic enough to advocate the 
abolition of the Hy should hesitate a moment to 
advocate the far simpler, smaller, easier, and far 
more important zi'ork of abolishing those germs 
that alone can make the fly a danger. 

In brief, the method, and, I believe, the only 
rapid, complete, effectual method of abolishing 
human tuberculosis, is this : find the ''open'' cases 
and prevent the spread from them of the germs 
they alone throw out in numbers and condition 
to be feared. That means, find the one person 
in every seven hundred whose infection threatens 
all the rest, and supervise him just enough to 
keep his discharges from entering other people's 
mouths. 

How is this one person in every seven hundred 
to be found? Not without hunting, not without 
ingenious, skillful, deliberate, sagacious, well- 
trained hunters, epidemiologists as devoted and 
persistent in their work as the average insurance 
agent is in his, — men who devote themselves to 

116 



the abolition of tuberculosis as whole-heartedly 
as any merchant does to making money. 

And how? Where shall we begin? Must we 
canvass the whole population one by one? True, 
that would do it, but epidemiology has found a 
simpler, keener, more scientific, far more eco- 
nomic plan, illustrated for typhoid fever in a 
previous chapter. Begin with the known cases 
and search the zones of infection surrounding 
each for mild, unrecognized, and concealed cases. 
(In tuberculosis the search for carriers is proba- 
bly unnecessary, certainly at the present time.) 

''But why not concentrate on the incipient lung 
case, the case that may be cured, and by prevent- 
ing this case from going on to the ''open" in- 
fectious stage get rid of danger to others thus, 
instead of by attention to the open case?" 

For several reasons, the abolition of tubercu- 
losis through care of incipient lung cases only 
cannot at present be accomplished. 

1st. Because incipient cases, in the truly in- 
cipient "non-open" stage, are discovered, per- 
haps are discoverable, in a very small percentage 
only of their total number. 

2nd. Because a large proportion of the in- 
cipients so found would not go on in any case, 
whether found or not, to the open stage; and 
the time and money and efforts spent in finding 
and supervising them would have been relatively 
wasted. 

3rd. Because a certain proportion of the in- 
cipients so found would go on, in any case, to the 
open stage, and thus become infectious cases, 
despite all efforts. In these alone would the ef- 
forts expended be of service in preventing new 
cases. The trouble is that, in the incipient stage, 

117 



it could not be determined whether or not the 
case would so develop. 

4th. Because the time and attention devoted 
to incipients, to prevent them becoming open 
cases, would imply, as it has, alas, so far im- 
plied, neglect of the advanced ''open'' cases, in 
which the danger of infection is so immensely 
greater. 

5th. Because if all the incipient cases were 
discovered they would form a mass of persons 
so great as to be beyond handling properly by 
any at present even dreamed of force of attend- 
ants, etc. If, as at present, only a very small 
proportion were found the actual situation would 
not be materially changed. 

''Would you then cease the care of incipient 
cases in sanatoria, and concentrate wholly on the 
advanced case?'^ 

No. First, because the tuberculosis sanatoria, in- 
tended though they are for incipient cases, really 
handle very many "open" cases, and to that ex- 
tent prevent new infections ; secondly, because 
the tuberculosis sanatoria do, in a measure, fulfill 
their proper function of cure for incipients and 
even early "open" cases to some extent and hence 
save life. But as a means of abolishing tubercu- 
losis, the ordinary tuberculosis sanatorium for 
incipient cases is quite hopeless. 

The thing to do first is, find the recognized 
"open" cases, whether they be in early, advanced, 
or late stages, and place them where they can 
spread the disease no further^ Then search the 
"zones of infection" surrounding them, i. e., their 
relatives and associates, for mild, unrecognized 
or concealed cases, and also for incipients, han- 
dling all "open" infectious cases thus found, in 
the same manner. This system would begin at 

118 



the ri^ht end by stoppin^^: further infections, and 
would incidentally find those early ''open" and 
''non-open" incipient cases wherein sanatorium 
treatment would be of most avail. 

SUMMARY 

Tuberculosis is a typical infectious disease, and 
it must be handled on the same principles as any 
other infectious disease ; hence, by blocking the 
routes of infection, but chiefly by finding the 
sources and preventing spread thence. 

Of the five great routes of infection, — water, 
food, flies, milk, and contact, — human tubercu- 
losis travels chiefly by contact, through sputum, 
mouth-spray, and hands, directly, or almost di- 
rectly, from patient to prospective patient. Prac- 
tically, it is spread exactly as scarlet fever or 
diphtheria is spread. Public flies and public food 
supplies are comparatively insignificant convey- 
ors. Public water supphes are almost negligible, 
and public milk supplies act chiefly in conveying 
cattle tuberculosis to man, although, if the milk 
be handled by tuberculous humans, it may con- 
vey human tuberculosis also. 

It is evident, then, that blocking of the routes, 
since the chief one is contact, involves chiefly the 
far more important measure of finding the source, 
just as in scarlet fever, or diphtheria, and if 
these sources are found and prevented from gain- 
ing access to the routes, the routes may be disre- 
garded. The measures for finding the human 
sources, practically the ''open'' cases of huig tu- 
berculosis in the human, are epidemiological and 
have already been discussed in principle before 
(Chapter v') 

The measures necessary for finding the animal 
sources (infected milch cows) are the w^ell- 

119 



known tuberculin test of herds, with proper re- 
petitions, and the ehmination of the tuberculous 
animals. Serious enough as cattle tuberculosis 
in the human is, its prevalence, nevertheless, is 
much less than that of human tuberculosis and 
its infectiveness tn the human is nearly negligi- 
ble. Hence, if our efforts were concentrated 
wholly on human tuberculosis, more cases and 
more deaths would be prevented in one year's 
work, than efforts on bovine tuberculosis, how- 
ever successful, could possibly achieve in many 
years. 



120 



Chapter XI 
. THE CONCLUSION OF THE WHOLE 
MATTER. 

THE DOING OF IT 

If previous chapters have succeeded in the very 
earnest attempt they made to show what the new 
public health principles are and how they have 
become established, the one momentous matter 
in public health still left unsolved is this — why, 
why, why are not these principles observed? If 
we know how to do it, why is it not done ? 

Chiefly, because the general public does 7iot 
know. They still believe religiously the theories 
that were beginning to be discarded in scientific 
circles twenty years ago. To any one who has 
discussed these subjects before lay audiences it 
becomes most evident that people the most re- 
fined and educated still believe, concerning pub- 
lic health, almost the same things that the most 
ignorant hold. So long as these beliefs control 
public opinion, so long will public health lag far 
behind other advances. Four of the most com- 
mon fallacies the writer's experience of public 
discussion has elicited are illustrated here, and 
the reader may easily test his own state of knowl- 
edge by asking himself what answers he would 
give to the questions here presented : 

THE CHIEF OBJECTIONS. 

1. If the disease germs are not evolved afresh 
from dirt or decomposition, but are descendants 
of their forefathers, where did the first disease 
germ come from? 

121 



We do not know. Where did the first wheat 
come from? Or the first horse? We know that 
we can get no wheat iiozv, except from wheat, 
nor horses except from horses. These germs are 
plants or animals, exactly as wheat or horses are. 
That they are tiny no more changes this law of 
descent than does the enormous size of a whale 
or of a redwood tree. ''AH life from life" holds 
true in nature through the whole scale, from 
germ to human beings. Besides, under the mi- 
croscope, we see the germs ''descending'' from 
their forefathers. 

2. If dirt does not breed disease, then why 
are dirty people so subject to disease? 

Dirty people are no more subject to disease 
than clean. Infection, if it reaches either, may 
yield disease in either ; if it reaches neither, 
neither will suffer. If an infectious disease en- 
ters a household, the dirtiest people will not 
spread it, despite their dirty habits, if they avoid 
the one specific ''dirf (the discharges of the pa- 
tient) which alone is harmful; the cleanest peo- 
ple will not fail to catch it if, in their general 
cleanliness, they neglect that same specific "dirt." 
True, dirt, carelessness and disorder offer some 
indication whether or not the people who 
show these characteristics would have the sense, 
or take the trouble, to avoid the one dangerous 
"dirt," should it appear. On the other hand, 
cleanliness, thrift, and system indicate characters 
likely to handle infectious "dirt" with the same 
care they show in other matters. But the dir- 
tiest people who make the proper efforts to avoid 
infection can and do many times escape, remain- 
ing as dirty as they please in other ways. The 
cleanest people who neglect or do not know the 
methods can and do suffer. 

122 



3. If you tell people ''dirt" does not breed dis- 
ease, you are praising dirt — upsetting all the 
careful uplift all the best people have attempted 
for many, many years. 

Suppose a ivatcr-p\pe is leaking in your house, 
flooding the floors and damaging everything. 
Suppose that when the plumber is hurried to the 
rescue, he tests the oa^-pipes, finds a leak, stops 
it, and tells you all is well. What would you 
say ? True, the gas leaked ; it was right to stop 
it : but the zuater goes flowing on ! Suppose to 
your objections he repHes : ''But think how bad 
the effect would be on our campaign against gas- 
leaks, if we failed to urge that gas-leaks must be 
stopped, w^hether that stop the water-leaks or 
not. If I admit that gas-leaks have no con- 
nection with water-leaks, you would let the 
gas flow on. I must make you believe the wa- 
ter-leak depends on the gas-leak, else you won't 
fix the gas-leak." Stopping gas-leaks cannot help 
water-leaks nor vice versa. Reducing disease 
will not make people "clean," nor will making 
people "clean" reduce disease ; only the one 
"cleanliness" of avoiding infected discharges will 
gain this end. 

4. Why do you talk so much about disease? 
Teach healthy living, keep the body strong, well 
clothed, well fed, and you need not fear dis- 
ease, especially infectious disease, at all. 

This is a fallacy so widespread that even phy- 
sicians teach it, in good faith, without consider- 
ing that they themselves would never let their 
own children, be they never so healthy, run with 
a measles case, or mumps, or scarlet fever, un- 
less their children had had the disease before. 
If the teaching is not good enough for practical 

128 



application to physicians' children, it is not good 
enough for public health. 

You see, everyone knows that children who 
have had measles very seldom take it a seccfnd 
time, and this without regard to whether they 
are robust or sickly, healthy or weak. Every- 
one knows, too, that children, healthy or sickly, 
who have not yet had measles, almost invariably 
catch it if they are exposed. Practically, the 
same is true of scarlet fever, mumps, whooping 
cough, smallpox, chickenpox, etc. It is not so 
true of tuberculosis, diphtheria, or typhoid, since 
those who have had tuberculosis, diphtheria, or 
typhoid may get it again ; although again with- 
out regard to whether they are healthy or sickly. 

In measles and the other diseases like it, per- 
sons exposed who do not contract the disease, 
escape, not from good health, but just because 
they have within their bodies a certain antidote 
to the particular poison of that particular dis- 
ease. Anyone can prove this to himself, if he 
will think a moment. If general good health 
really did protect against these diseases, a child 
who could not catch measles, because pro- 
tected by his general good health, could not catch 
scarlet fever, either, for the same general health 
would save him from them both. But everyone 
knows that the child who cannot catch measles 
(because he has had it) must nevertheless be 
guarded from scarlet fever, unless he has had 
that too. In brief, an attack of these diseases 
gives, in most persons, an immunity ; that is, an 
antidote is formed, which then protects them 
from having it again. But there is a different 
antidote for each disease. Having had measles 
once is excellent protection against measles, but 

124 



it is no protection at all ai^ainst scarlet fever or 
mumps or any other illness. 

In diphtheria an antidote is formed, but often 
disappears again, and therefore this disease may- 
be suffered more than once. In typhoid also an 
antidote is formed lasting a year or two. We 
know and are learning more of this antidote 
against typhoid. We do not know yet much 
about that which perhaps protects against tuber- 
culosis. 

Now, no one dreams that the antidote for 
measles can be developed by diet, exercise, or 
clothing; by fresh air, drugs, or anything in 
fact, except by suffering an attack from the 
measles germ. Nor can anyone seriously be- 
lieve that the antidotes for typhoid, or chicken- 
pox, etc. (except that for smallpox vaccination 
takes the place of an attack of smallpox) can be 
developed except by equivalent means. If ''good 
health'' will not protect against any of these 
diseases, taken one by one, how can "good health" 
protect against all of them taken together? 

So w^e might deal with fallacy after fallacy, 
all based, however, on two. 

POPULAR FALLACIES 

The first of these is that infectious diseases 
come from ''general bad surroundings.'' The 
truth is that they come solely from certain germs 
growing in the body, and practically the only 
sort of "bad surroundings" which cause infec- 
tions is association with one of these infected 
bodies or with its discharges. 

The second great basic fallacy is this, that 
"g-eneral good health" protects against infection. 
The truth is, that the only true protections 
against germs we know are, first and best, to 

125 



keep them out of the body ; and, second, to have 
within the body the special antidote for each 
particular germ. We vaccinate against small- 
pox, but that does not save us from typhoid 
fever. We vaccinate against typhoid fever, but 
that does not save us from smallpox. If we 
could vaccinate against every disease (as per- 
haps some day we shall be able to do) we would 
be safe, despite the germs, at least while the 
protection lasted, and after that we could vac- 
cinate again. 

But how much better to avoid the germs, which 
means avoiding the persons in whom they are ; 
.and then we would never need any sort of vac- 
cination ! 

Surely, the thing to do for one's own sake, 
and still more for the sake of our associates, is 
to find the infected persons, or animals, that alone 
can cause disease in the, true sense, and keep 
them so protected while the danger lasts that 
they will do no harm. Then, when their stock 
of germs is dead and done with, remove all the 
restrictions. 

NEW FASHIONED QUARANTINE. 

You will say that that is only old-fashioned 
quarantine. It is, in principle, but modern prac- 
tice changes it so completely that, practically 
speaking, new-fashioned quarantine differs from 
old as much as motor cars differ from camels. 
In the first place, old-fashioned quarantine did 
not pick out all dangerous persons, but took the 
sick who form but part of the infected, and also 
took the well who were found with the sick, 
including thus some who were not infected, and 
kept all these practically in prison, in their homes, 
or ships, or wherever else they were staying. 

126 



Thus, not alone were many infected persons 
overlooked and many uninfected persons wrong- 
ly held, but also the disease spread oftentimes 
from those infected who were in the net to the 
uninfected who were kept in with them, so that 
old-fashioned quarantine, while it protected the 
community but partially, meant often poverty, 
disease, and death to those caught in its toils. 
No wonder the very name of quarantine makes 
many people shudder. 

Xew-fashioned quarantine is not a blanket 
method, blunderingly catching in its blindfold 
grip both sick and well, the harmless and the 
harmful, indiscriminately. Xew-fashioned quar- 
antine requires definite detailed knowledge ap- 
plied with care and patience, not mere force. 

Xow, everyone wishes infectious persons 
handled so that infection ceases. Even the in- 
fectious do not wish to spread their own infec- 
tion. The thing that chafes and riles the aver- 
age person is not restriction but unjust restric- 
tion ; either restriction of non-dangerous persons, 
or restriction of some of the dangerous only while 
others just as dangerous go free. 

Xo mother minds the exclusion of her infec- 
tious child from public school, if her neighbor's 
infectious child is excluded also. Every physi- 
cian would report his cases if every other physi- 
cian did so too. 

Here then is the solution, based on human 
nature, on common sense, and on the most scien- 
tific knowledge. Find, through the methods of 
epidemiology, of the laboratory, and of the vital 
statistician, skilfully combined by experts, these 
dangerous persons, whether sick or well — these 
only dangerous persons, those who carry on them 
or in them, germs of infectious diseases. Set 

127 



all others free, but keep these persons, not in 
old-fashioned quarantine, but under such con- 
trol that their discharges will not pass to others ; 
and do not measure the length of that control by 
fixed time limits, blind and unjust as quarantine 
itself, but measure it wholly by the length of time 
the germs remain in or on the body. The moment 
that the germs have left those persons they are 
no longer harmful and they should be freed. 

To do this properly means intimate attention 
and supervision of infectious persons by men 
who know their business and do nothing else. 
If one such man to every 20,000 persons began, 
tomorrow, everywhere, his work, infectious 
diseases in ten years would have vanished and 
would have become mere history. 

SUMMARY. 

This, then, is the conclusion. The old ideas 
have passed; the new are no longer theories but 
facts ; the methods they require are not untried ; 
they have been practiced for years in Minnesota. 
The details are worked out, the field is ready, 
the scope and cost are known. All that remains 
is to apply the methods developed in this state 
to all infections, thus wiping them all out, once 
and for all. The way is clear, what remains is 
to follow it ; the method is known, what remains 
is to carry it out ; the thing we, as a race for 
centuries have prayed for, can be done; all that 
remains is to do it. 

Each generation of Minnesotans pays now for 
infectious disease two hundred million dollars 
at the least, and has the diseases, too! Why not 
pay one-tenth this sum and rid ourselves of all 
of them forever? 



128 



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